01050160CITY OF CUPF.RTINO
BUILDING mvlslOry - ' PERIVIIT�,„
CQNTRACTOR INFORMATION `
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BUILDING ADDRESS:,
PERMIT NO
OWNER'S NAME
1.0811 .ALDERBROOK' LA; , n:. -
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APPEICATIO IIiA • "6 : " "i`99'I'
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SANITAR YN ., Gl..
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4 ARCHIIIC'UENGINLIR 4f
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( BUILDING PERMIT INTO
BLDG ELECT 1 PLYM5--� MECH .,
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_ - LICENSED CONTRACTOR'S DECLARATION
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' Job Description'
p I hereby affrn that I licensed d p .' n. fChapter 9 ( n g
Safmor 7000) D' tour Prb(sdrz,Cdc
y with of TI,B and and my license
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Data ��I-n1C�41�CTSDECL R) N.
SEWER.;,LINE: RERAI.F', :'y :
I mode ra w nv nl s shall no used as pa a rdcom5
Licensed Professional
m OWNER- RUILDER DECLARATION
1 h b) aff tM1 net a exempt f Ih Contractor f Law for 00
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C Coll g dralue. ,Sect n 7031.5. Business and Prefie7sions Code Any capilar county
q wh'eM1 require. a permit in mount all npn ve demolish, or repo r stay "ime ud
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prmr m it, issuance, also reyuims the applicanI for such permit m file a signet statement
'that
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- •Sq'..Ft.FloorArea
,'Valuations
- ]'a111censed ....... tt the p - : nnc Nd.� L (Chapler9
(a 6 d 5 coon ]000) of D'P 3 f Th B :' d P f Crude)
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ofSeth'' ptd , 0 toot,
erf ,M1 IIld ept AY Icon
ofs f edged by ydeedd ki for Permit hens the ppl a lln ucv'I penalty
of r n,hanlvehudrWadR „,„(sson).
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y.0ccupanay.T$1{8r '
col f (lie property, Y employees with wages as 0 °r sole compensator,
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will d (lie wook. and the structure is , intended or impanel bit -: (Sao. 70111.
Bt s d P f ss C d TI Connector', Cc : I I t pply t
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'wW�G. O4 jRC„ fired lnspeeti6ns ”
rof property Who had. p t thereon, d h des such workhmelf
or Through his own chn,loyea, prr v ded red each imp dveme t, the a fronded or
offered f If, r 'rmeTariff, ,, impne,ene,lor . Id withrin one y I., of
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'imppl `r, thm iok5 vill th n a rp BIN th dd tb Idol
10E�I�. Eloi • „& WA EiR
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202 -I L1NDERFLQOR, PI I;IhIB TIVG tee. ,
rod - of the p pay h: ly nor utg thlc d vat ,
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a T t t p d ct (S m. 9(94 Busirce, ad Profession, Clad) The C a m rn.
+' ' R7 4GHaiG IIMB'InIG
L red do t apply loan r f,mP Y h Id p , theme,
'' f ouch pujecte with wnbaT rtv) I d crown ant , the
CoAt ht
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TUB, - R- ORK�AF1-f„7WF- R%�a,'..•,'. '
3of 2,
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. License Law
❑I na.xemptanderSao . Bmrcra;tmarca.en
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�OE�;- ! :FITIUAIL' PLtP ,)j31INGtr,E;NERG,Y,,*, --
Etcher Dole
506, GAS rES'l a...„}
WORKER S COMPENSATION DECLARATION
507, . - F I I,sll? j, PLUMB I NG•�o
'I hereby affirm under parity of pi jt ry one ordaef all n, dwWraions :'
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+� I have d oill maintain a C difilred 'If Conooll on If f-
-'eardparearid, as provided L by Sc ,ii( 3700 ,1 the I h Coole,.fier he
Tritium f,l oarklor.lach this permit I, issued.
El I havoted will runintrin W.” k. , Clou're.fird 1�. q' J�y t
3]W ft r the pn ft k h this p I
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issued, MyC np aT'minsr per APOIy herarce ,
rc� 9Jr�rc��
Carrier J�� Pol yNY p� �
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'F CLRFir—icATION OFEXEMPUON FROM WORKERS'
COMPENSATION INSURANCE
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' eninn need tat he couplet d'[n p alt is fo and hundred dollrs
orle
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I wnify ,Inn in the ratio rnalso of dire wank rnr which this permit is i,csncd, I,
shall not employ any person in any manner sn Tee te becaime'notice, no The Work,,,'
"Compensation Laws of California. Date to
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' NOTICE TO APPLICANT: IL nfier makith, hie Cenifien,e of ExenapTion, you should ,
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becomo sabjecvo the Workers Compensauoe pow,sa e, m It, Labor Code, ymn im,
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Ior,bwuh ennply with such provisions or ,his permit shall be deemed mocked.'
' CONSTRUCTION LENDING AGENCY
I locichyaffirin that there., i haduagagency f r the peeler mere
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lifthe 1.11, fee which this permit I, i ...ed (Sea 3099 Cie. C.)
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Lander'sName f -
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LendrIsAddress
Ict try thin Ih Id'.pll't ad ta,a Lou h b information
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cents. I b' to - ply with all city ound courany unfircences and stale I t
,oh Id'ng consncfon and hereby authorize representatives of this city m ether upon
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r 'he above manniorool per,"Ify f .. oil , spectimn P p t
s (W)s.I t, act,, irdeannuffyond kpl I.. theClYf Cupertino bid
1 liabilities joid,mat . T d Is p vs which may in any Y e aboard, said
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•'Issued
Gt n sa,dome oT th grunn, offl permit
A TUNDERSSNDS AND WILL COMPLY WITHALL 'NON -POINT
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by: 'Date / 10 �•,a
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nature n App icmn ere - .. Dole ,
Re -roofs -
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H A MAI'LRIALS DISCLOSURE.
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Will The tpp! , , bailm ng occupant share ... handle hazardous martial
Type Of ROOF a
Tare defined by the Chardon Mud ci,f Ca le, Chapter 9.12, and son Hmlth and safely,
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Code, Section 2592107 1 1
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El Y, El No
All roofs r -
- shall be inspected prior to any roofing'inaterial being installed.--,,'
- wu the ppl t or future Inuldill, care,cat use I a 1 1
deusa-con,
1f 'a roof is installed without first obtaining an inspection, I agree to remove' +. •
cmth ants as dc,nad by ,n By Area Air Quality Managunent
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all new materials for inspection.. Applicant understands and will comply with
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all non -point source regulations.
1 have read the hazardous ntareriale reyuiremen,s it Ch' 6.95 of the:
Cal T m'a He Rh ad S f ry C d Sections 25515 25533 mod 215-14. d re J'har.
normal I I' e l . a o t that,, : Y P 'Ml ty t ffY the
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whit
normal t faire ayu'r tofu which sous, be neT pr r9a iss v of s Gen fir m of
O\
Onupan
Signature A cant Date.'
., - All roof"coverings to be Class "B" or better
au,nddrw agent Da,e
,OFFICE It " -