01050155 CITY OF.CUPERTINO
PERMIT BUILDING DIVISION CONTRACTOR INFO+^aRM'A TION:' E' w
IBUILDING ADDRESS " d, PERMIT NO `
' 21730 ALCAZAR'+ AIIE. „. .. ..r, ' :,y • r.,. . :47.1'050Ji'55,•':.'
I OWNER'S NAM1IE — I ” - 1 APPLICATION SUB DATE
C13-I'A0-Fl1 .CHMe- i�, SIIE-FA / C)'UV8s "„iU5t;18 1220.1.
PHONE ., $ ., SANITARY NO CONTROLNO
O O ARCHITECT/ENGINEER BUILDING PERMIT INFO
sector / BLDG`, . ELECT PLUMB M11CCH
8z4—m +. LICENSED CONTRACTOR'S DECLARATION JOb,Descrlptlon .,
1 hereh rliue that I tun becmed Imdel rCha t,9lconnnere r
❑ r a pros Pme n p e .. .
F4Cm with 1.11 arre barreled OfDlvrann3 oaths BOSrnee,and Plnfeaions Cnde.and my Increase '
6 .•..at1 is at Inree and street CMf•f`/ r
�KC.¢ Leense Class '°Linty "'r°rat-•1''u^IS:AI”
Data Clememia
ARCHITECT DECLARATION
l=w�iO; i understand my plane ball he used its pubLa methods t
w 6�'a Licensed Proresemnal
OWNER BUILDER DECLARATION _
I�r 1 hereby air nn Ihul 1 nth enempl from the Chromium's License Law for the
Inflaming reason(Section 7031,5,Hu,me,s and Pmhssmm Code Any city or county I
❑ whmh requires a proud In umarmt,alter,unplwc de mrahsh,or reptur ally structure y
. m Poona u,Iaeuanae,sl,o re......the aptha.nl Bonsai permit to file a,l ed statement
5555 that re,le,el,edpurFUamto to, m 1,ran,oltheCanlmator',LlcenseLawlChanter9 Sq. Ft. Floor Area Valuation
,,,,mmeoung with SCUm 7WI,,ifD..., ,n 3 of the Business and Team......Car -
U u l
mat net,emor mereo-om and th ha,I,for the,aieged erempndn Any smaller - - . �
I Section 7101 s by any apphmm InI r permit unco,the applmam Io a clvrl caralt,
n ssoo t almnremanrtaenanaredanllal,(85an - APNNumber' Occupancy Type ..I a�//99
Ji11.'av owner of the proper),ur my ca lo)ee with wages.as thevsole campralumn. ;'571 nVI-i : .171t7l�
11 do tut marl,and the structure is nil amended or altered lot sale ISee 7044,
Hu..nt,.impPmu,nu n,Cade The Coal ra.too',Lmemc Law does not apply In am - Required,Inspections. .
owner of prapeny Who bolds or impurities th6con,and who does such work himself .
or ough Inn own employee, provided that such rmprawments are our intended re 4ibASS•I GM1IEU '=I NShEChaI;8lN5;;M .
offered fn,ale If,Inotvever,the building or Improvement Is sold within une year of
Mcompletion, e owner-budder mill have the burden of prming that he did not bndd of '
m
ME tar purpu,e of sale.l.
711,a,owner of the t(Sea 71 am Baninevely cimmchng M' Lev) I h Car neliu 's '
' omen, the due,ice(Sec Ito a Bmures and cu,who'b'G,lo 1'I he Cammcmr's
d' Lmenw Law tract not apply man owner m a soul)who halide sedpursu s thereon; -
d vPoo contracts for such pmjnt,with a umnttcnmisl (sensed pursuant m the
ntrawif,Lmenw Law,
I ua,exempt under Sec: R& C for this m on . t
Owner Dam S //� /A'
RKF.R'S C ENSATIONrIJP.CI�JkI I a' , •.
1 hereby:Jlirm under penally of pepury out of the tallow Ing dedartnrono
❑ 1 have and mill
' nu a Ccroac of Consent ,elf-mwre for Waders
C n a ld,d Ern by Sccul.n3J00 of I he Lh CnJe, for he
performance o r ram mark for which this permit isis sued
°1 babe and
,
will r Code, wmle pa comprmahnn a work m reyumea by Semam .
' 1T)B of the Labor Code,tor the pmmrrancee of the wort for numb lhn Perron is r
Issued My Worker Cnmpemaunn Insurance curacy and litbvy number in
' 1
Carney Pahcy No •• •• ;;x '
n - CERTIFICATION OF EXEMPTION FROM WORKERS s + I r' 1, '
COMPENSATION INSURANCE. + - ♦w`, .,
.. .. 1 . ,^l �.r
fl'hls war need not be mmplemd if the permu is tar one hundred dollars
ISIPIT or le,n l t ,
1
cA ify that in the' furmanae of the roll for ash ch this '
per canna to awed.I
,hall no("employ L any tenon m any tun n,to became snb)ect m the Workers'
Compensuhon Laws of California Dntanm •. L.
Applicant , 'r
NOUCE TO APPLICANT If,nfmr mukrng tun Cecil&am of F empmrn,you nhnuW '
hearths whyed m the Wnrler',Curnpematimr pmvlanm of the Labor Code,you mull
zO O fnnhwnn wmply wuh w.h prnvmmns sir mis pernnl,hall he deemed revoleJ
CONSTRUCTION LENDING AGENCY a
> '1 hereby shame that Ihere I,a construction lend,.,agency fir the performance
W al the work fur which this permit is reared(See 1097,Cu,C.I• ,
4 Q 'I,enJrri Noun,z Lender',Addres - ^ - -
V'0 herb fy that l hat tread this apphcmimr ,hit state that the above nuamaear
r is
W [.y enamel I agree la rarely all roomy nrconsumer.and state law,relatmg s ,.
O f, to turning constnmtion.and nemhy aamnrae repmeemnme,.robot fly m Mloun,or
r� the rhave mentioned property for Inspection purposes ?p,
p,I IWelagre leseve,mdcmmf)and keep harmless the City of Cuperno against to
i..i Vi Imhdnm>Iudgmena,a.,is and eatensus whsh may no une way arerae against card
V' Oty m conwqucnec of the grant of Ihu ite"a t '
APPLICANT UNDERSTANDS WILL COM1IPLY N'ITHA oNPOI Issuedb "� %�'�'. � ��..Y���
a C SOUR RE�ULATIONS •� Y: Date .
Signal n A,eaC Cnnmaam ,•; Date. Re-roofs ; ' .. .•,
AZARDOUS MAT. A'S(DISCLOSURE,
Will the appbend no future ltnddingr,Mpare norce,handle Intention,material ';Type of Roof
as defined by the Cupcmoa Municipal Cade,Chapter 9 12,and the Health and Safely'
Cadc,SCenan25512(y)°,, ♦ 1 ,+•
�" All roofs shall be inspected prior to any roofing material being installed; '
Will the.tpphaam or wwre building oecapaot a.neywpmemordedck which If a roof is installed without first obtaining an inspection, Ifagree to remove
in at h...thus on,onmmmant,a,defined by the Bay Are,Am Quality Mums,menl
DI,aI`toree \VNo all new materials for inspection. Applicant understands and will comply with
,'all non-point source regulations.
1 have read the Institutor,materials mgnnences under Chapter 6.95 of the '
Cahfimrd Health list Safety Code,Secmms'_55U5,25531,md 25534 I Ma ratmJ that ,
- lithe buddmy does not curtrnlly have atenant,that his My b,ponsibht,m rally the -
naup.mt nl the rcywrcmenl,whsh a the in',tnir I I,wnnce of a Caruficatc of ' -
Occumcy ..
Signature-6f Applicant . . r Date
Over,eI m aaroaal gym A ,Date All roof coverings to be Class"B"or better
b' # ' OFFICE.