01020085 CITY OF CUPERTINO -
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BllII DING AUIJRESS, `PERMIT NO p' ••�,/�,{-,' Y "
AE)R1-. 111A 1111 QI,ON `" . 01020085 "' ••
OWNER'S NAME! .. - APPLICATION SUB PATH ,
I, UEN ,1:Aj.lEr`d 1012/15/200t�10NE } ..1 ' SANITARY NO.' CONFROL NO -
0400 ARCIII'1'HCT/ENGINEER " " BUILDING PERMIT INFO
m_ "+•• BLDG ELECT PL MR AIECH
LICFN%DCO1sURAC'IOR'S DECLARATION
I hercny.nfimt mat la heen,ea andc,,ovnlir,of chain,,9 aamo,wall Job Description .
e'n6 Section]II00).fDlvnlon Jufthe Brame,—ad Trofe,wm,Cod0.endinl humor
is Pe a l and cfc
Liom,eCla r .I,ic b# l WRTERHERTER REPLACEMENT --
°� D:t1 a,nalm
Y O G ARCHITECT'S DECLARATION .
so I undnamd my'].a''bell be rwJ 1}tuM1Lu at
ip O I.,,ce,d Putfc,c.ral " I ' e• '. ., ,
XX •• ItWNI. -BUILDER DECLARATION -
1 Lerch,'Hint"thn 1 am eumpt tntm the C•mtraclnl'v L¢en,e Lnw fur the
ti
G f Inch r g reason.pernet t ]IIJ 1.5,itn,"ee9and Professions, an Cnde Any ray or mum,.
• S�. p xh¢h rcgwree a pclmn w umalvc(,Ater;Iuipmva,deniolnh,tar NPmr any mu,mre t -
1 prior to n,deuan,e.nlw regmres the ali'l I let w,h penun to Men a tined statement L '
Fitt wl,Il,dn,ed pnlr,raatm the lieavnslill,mdes cinln,Tirsl.I,en,e Lawlennpteeq
- Sq..Ft, Floor Area Valuation '
(cumntenung with Sccunn 700Nb of Dlmaun l of the Business and 1'ndc,>Inm Calr)
or the he is 1x¢,11,1 therefrmn and the brae for the alleged ereni,ann Any vell,lo n '
at Sect inn soy any apph,am roar pemnsnnle"stw:Ippfieam u1a11vll penalty, �� '/ '$1
p\\I r pit more than five llondAd dollar, 55000 APN'Number Occupancy Type
Nienwneiot thepmpen"'amy enlpinyee,won w:tsc,its 1]11,1 sole c...pmvannn,
will do the work,and the stmnnrc i,not Intended fir oficled fat ,:de(See.7044, �I�.V�4..�,_•.—. ��
Beall and Profession,Code The Contractor,Lleen,e Law does no(apply to tin 'Required Inspections '
owner of pmpeny Who hold,or improve,thereon,and who dues such wink him'elf '
or fl rough his own ennployce,,provided that such Ilnpmvenives arc n"Intended ur
eueredlot sale 16however,the bnddngorimpmv"nmt't„oldwimtn line year of lab — 5EWER 8' WRIER
an( plcmn.metoncoholderwd]have debiodatOf ron,that he did noballoon ' "202 — UNDERFLOOR PLUMBING .
nproo for purpose of safe I , , -
'of,.is owner of theprolcny,ante.ausicIY Lainacnng w IF foined contraon sa - .301 — ROUGH PLUMBING . . -
Lansnunt(]to png,n(Sec.7044,Business and Poce,aens Code:)The Co"m"or, 302 -• TUB R OR SHOWER .
icemc Law ate,oat apply li an owner of plopeny who hnudv or nnpnnxs Thereon,
and won 1anI1a11, 101 atoll"ect,will.I lealeacnn,I bccnvxd poenrm in the 502 — FINAL 'PLUMBING ENERGY
Corr co',Lucn,c I,ax ... r .
0I am e.einpt tinder set. ,-B m P C ter This reason 506 -- GAS TEST'. . .
��.
Owner DOS ON DE 507 — FINAL. PLUMBING `
W KER'S COM11I'F.NSA'ION DECLARATION - -
I hereby affirm inert ponally al pepury line of the falls,w mg Jeclaranom'
r o
J I have and will mo,eccd a Certificate Sent of 3700 it it)eeLabor roe ha,th's
�rini Inntice., m provide) tai Fy Seclmn ))1111 fir the Labor CLJe. ion the
- perfol ounce fit in work for wh"h thi,permn is ISamJ
❑I hoe nnJ will m"nlaui Worker',Competnaican Insurance,:n required by Scu am
4]IXI of the I.ahor Cud,,for the perinrmame of the work rte whsh this permn is '
owed My Workers Cannpcmnuon Inwnmcc Lanier Ind Tolley nuinber,ve:
Castel ." •.' Wb,y No
CERTIFICATION OI'EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE _ - d '
phis wemn need ism be',orar,led If the permn w for ona Inndred dollars
IS 100)it lost r '
• I cemfy that In the pertonnan,e of the work far xhicb this peril is issued.
shall nat et reel.,any,also In any..tanner,i as in became wbjecl o the WolABi
Connpboolnn Lars of California Dare. -
- APpinunl. L.
NO ICE'IOAPPLICANT:II,nfierm.IAingthn Centlicaanf E,empnon.ynu stand
,ZQ0 ebee,a "In the Workers Cinnpensation nevnion,ol(he Intar Cnd mud e,you
nmble forthwith,amply with eneh provisions orlhtcpenun shall wdeemedrewked ,
'^ CONSI RUCTION LENDING AGENCY t '
a ' I helm,aBlrm than there i,a um,uu,wm lending ins ey far Inc perlunrance
of the work fir which this penun Is tseucJ(Sec.)1417(Co.C I t ,,
2 ,Lender',Name" i. • 1 1 ' ,
z Lender',Alen„
C.I Q I Lehiy that 1 have Icad this eprbcalnm.md au"that the above inramtaten Iv
ELI a rte,l I uglee ti comply wuh Al city and ocrt,.,fin: ces and,laic L,s minting
Q V to holJmgcingruwor.and hereby anthin,,nlm,en Dhve,ot this cop t enter upon
the above...in nailed PmpedY Lu".rent l purptne, .
F p.
(We I ague to onc,indemm),rod keep habi the City of Cupen"n against . . 1 •�
i..i V1 liabilities.ptd6menls,riot,and espen,m which not,fit any x,ry ill asa",t said
L.1 4 CIp In Lonsequenco of the grerlins of this permn '
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
p' ssuedb Y'BREGUI TIONS' Date
Z-/
sgneore arAa;It`ter �O>
;•. il,ll�. Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the arp, at it hnol nildiitg icciranl ,are handle hwaaan,Ina"oa Type of Roof .•
as Jefned hl the Cupe(mi Mt metpal Code,Chapter 9 12,and the Health and Safety
Code,Secuon 255321ay! e
°Yes �No - All roofs shall be inspected prior to any roofing material being installed. , . .
Will tile itpphl antorwor e'M1n de ns ac,u,uatn,o......emir desire,which If a roof is installed without first obtaining nIns ection, I agree to remove
' nrt h:nzardnu,an contannnun(p ,defined by the IIa,All.All'Quality Mamgeinent , g P ,g "
PF \ all new materials for inspection."Applicant understands and'will comply'with
o Ye,' i�1 Nn all non-point source regulations. '=
1 have,cud the he,fil Inalenal,requirentente under Chapter 6.95 of the .° I
Caliker"Beahh h Safely Code,Sections 25505,25533 and 15534.1 understand that
it the building dies.111 eunently hoe a leIan(.Ih:n n is my re,ry,aabih y to rout,the
ccipent fir Ile requirement,whl,h mua he met 11,11,'imssnenm of a CenJUale of
Ocen cy. ,
tSU Signature of Applicant Date
Gwne,orauthana,a L-t-� ' . ,.Dal: I _ All roof coverings to be Class "B" or better -
OFFICE '