00040021 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION ' PERMIT CONTRACTOR INFORMATION:
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HUILDINGADDRP g:
<, ^� - �� SANITARY NO. APP TIONSUBMI]TAL DAT
OW :H'S(NOIR^l L I YL���H, �l f NIC CONTROL'Mr��J\
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ARCI IIl'EC'I'IENGINEEH - el Z,-,��6/ (J BULGING PERMIT INFO
QUU L 6
�'Fx' '6v' LICENSED CONTRACTOR'S DECLARATION
O_ I barely affirm that 1 am licensee under provisions of Chapter p(commotion Job Description
j
=Cwind Satbn I000)afDivisionJofine Buairmaaand Aofdiom CMe,and mY liwn,e is
y z< in full Twee and<R
e ` 9 0� CCj o
i= I a_
w O License less Lic.M—
3 a H IN... Convacor f tl
F u.O a ARCHITECTS DECLARATI N
1rmnud my Plans"I the used u public raarLicensedP
I 1 �
sato.. a`✓<L dot_ YSllr�' 1
d d c
Licensed rofcsioml
I' OWNER-BURGER DECLARATION
z r I hereby aRrm that l am tth
exempt from e Contractors s:A., Law fm the
z D falbseas^^
win6 .(Saban]OJ 1.5,BusBusiness and ioaProProfession.ioCode:AnY city or county
3 m which missies a armit an construct.at.,,impro,<,demolish,or repair any etrumme Sq. Ft. Floor Area Valuation
later to its issuance,also moires me Wha t for such suemut o al file a signtreatment
that he is licensed pommnt m the positions of the Cantracatra License taw(chapter 9 OOU U O
(co asmgwithSection]000)ofDivisionSoftheBull.andProfessionsCode)w ppN Number Occupancy
that he is exempe b
t therefrom and the W basis for the ally ex<mpny lon.Avictim.of P Y Type
Section]031.3 by any applicant for a pernh subjab the appllcantto a civil samety of
sot mom man five handed dollars(5500).
❑I,aRawo<rarinapmpaty.nrmremployes.wmw.se=..meirrolaeampen>sean. equired Inspections
willdomework,and :The Conam,outmodedmow does not
to an owner
end Profestrab Cade:The tsm thaw's License taws such
nrol apply s if owner of
progeny who build or imped t a t such improvements,red who nos such ooh ded m of through
his own employes,provided r m such s soldw se not intended a .leered for
owns.If,hmvemr,thebrdlding i e. filemrntitadIswithinwmyearofrnmplerion,dm
,builder will have dm When of movant mat he die nm Wild w impose fed Four. ��
pond of sale.). /�
saw
I,u owner of me prolortY•un exclusively contracting with licensed connamon to 'S
construct ms poject(SM.]D66,Basins,end Professional Code:)The Conmeme'a LL
cane Lew dos rot apply a an owner of property also,Wilds or ammo,.tbrreon,W C7
who contracts for such poja,with a conuactoefs)licensed pursuant m the Contactors \/ ^7
License Law.
❑1 sm exempt under Sm. .B Ra P C for mil mamn
Own Due
WORKER'S COMPENSATION DECLARATION
I hereby affirm under par4q of priory oath of the following dee Wetios:
Q 1 hove and will maintain aCer ificam orConsenuo elf-insum for Workers Compeer
slim,u provided Ter by Sadon 3]00 of the Labor Cade,for Ile prfomuoce of the
ark fed which mix;,roil is iasuM.
]I have and will maintain Workers Compensation Insumem,as miluired by SmIsm
3100 of 0c labor Code,for me sadormance of dm work for which this permit is iamW.
Mr w eaampena.yyyyn l4 y w<.rtier me Policy neer Sdi 7 58
Caaeie `19-°/a'y AJ Islw�z I Policy N.,:
CERTIFICATE OF UEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This wriun neednot be completed ifis, .it is Torun hundred dollars($IN)
or is..)
1 certify slut in the padmmaae of the work for which this pemdt is Wood.I shill
nal cold,any Anon m any minter Re as o becomes cubjec,m the WorsenCompn-
Rama Lewy of California.Data
Applicant
NOTICE TO APMCANI:If,after making this Cenificase of Exemption,you should
become sabjm to the Workers Compensation provisimm of the Labor Code,you most
foMwith comply with such provisions ce this permit slit W deemed revoked.
CONSTRUCTION LENDING AGENCY
OQ
its
issued(m<lonlending aganry fwthe perromuae of
Z me work for which this memo is issued(Ss.l097,Civ.CJ
Lenders Name
'J lenders Address
[i] I calmly but I have must m19 epplicallan Nd Role that me a W,c Ird..IiDn la
A. 0 contact.I agate to comply with all city and county ordinances and Rum laws relating to
DZ building construction.and hreby authotm mommatives of this city to tour upon the
V O ehovcscemioned property,for insfacdon purposes.
{av E., (We)agree is save,indemnify and kap hem ms the City of Cupertino statist
O 4.) liabibUmjudgments.emu and eafames which may in my way mane against said City
y W in coducluea<of the granting of to,permit.
[� 0. APVLICANf I1NDERSI'ANUg ANI LL COMPLY WITH ALL NON POINT
UO
'(LURCH HIiC n 1
U y�S 00 D ZO
gig can oro Data
HALRDDUS h MATERIALS DISCLOSURE
winthe e CiStcnlor forum WJl Cede, haptemmue handle Health Rod Safety Re-roofs
u ll,dclinedSec by the Cuprtino Municipal CMC,Gallate,9.12,end No Heiler and gaPoty Type of Roof
coda troland,25aJzfal] _ YP
❑Y. CdN
Will the applicant.,future Wildingoaupant ommuipment oldiAwl which All roofs shall be inspected prior to any roofing material being
eWlluu,dous err conumimns ale defined by the Bry Area A'a QsWiry Mmegemenl installed. If a roof is Installed without first obtaining an inspection
DisaiaO Yea I agree to remove all new materials for inspection. Applicant
Lha emadth hawd.aR material�,ainmentR ands,L,Iapmrb.95 of the,Call. understands and will comply with all non point source regulations.
mens Health d Safely Code.Sections 23505.25 33 end 25536.I utedentmd has if the
ildi,does sot eumnJy that' y responsibility m Wify the measures
Orme t s o/a Crnificne f Pans',.
y^4t�� Signature of Applicant Date
Oomerm.wi �W�, Dam
All roof coverings to be Class"B"or better
OFFICE