00090044 . -CITY OF•CUPERTINO
BUILDING DIVISION ' PERMIT CONTRACTOR'INFORMATION.
BUI LDING ADDRESS:.c "j is PERMIT NO.
I 00090044",OWNER'SNAMG ' ' APPLICATION SUBDATL ,
u 9iiii20NTv.0
PHONE: 1�. "" - SANITARY NO. CONTROL NO
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ARCHITECT/ENGINEER: is I= f1UILDING PERMIT INFO
w F BLDG. F ELECT' PLUMB. MECH
- LICLNSED CONTRACTORS DFCI ARAI'ION -
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et a melchs nereet ,e It
FURNACE' 1.
w3wy Date .- Rntanor �.,
Is 0'e - ARCHITEC'T'S DECLARATION
vyvyy Y I d t d y pl h d be uaeJ P bl records
c, Lice :d Prof.:wall
n o OWNI R BUILDER DECLARAI ION
ce I lii by iffor.that I at tioap,d Ban thC I Urrame L3 f r the _
boll y Al 7031.58 :iffic,,,and Pinfin,ximm,Cd AY citycounty w. '
E t O
which Institute.,a Norn t nsvucq altse,improve,demolish,carp mystructure
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:prior In I,,.. ... I. retinues thic diramonechPe 'lI IIe.signed statement .
�4
Ill.,he licensed p : to IT,p t he Corroacturc License L (CI' ter9
(ere ,enc ng wro Section 7000)of Dnai 3 nn B d Protestors c I de) Sq:Ft. Floor Area ",Valuatioii
_ _orthat h pt Beemanand the btf the alleged exemption.A In - _
nf5 n 7031'.5by any uppl .unn far a p tsubject theaPd tin a civil pealb AP.N Number
P y�- OGGD anC e
or am more than lve hashed dollars($500) ^:(.+. p .
DI.as owner oFthe property, y plyc ith .g as(f 1 tpe .aton - -
w ll tic the work, J the Structure i. mat intended or offered lor Side(S 7t94 Easiness and Professions Code:The Contractor's License Law bees not apply.to an - - (,.t Required-Inspections ..
w r(if properly Who larlds or impraves lhemon and whaidnes such work n' t if
nrthmugh his own caniployces.w . provided atch-npnwwn titinteraction
oRnmd I,,,rine a rte he ,geit one r
' 301 — RQUGF , P.LUNBING
t��npmtnn meonn'b-m will base rootndd,mbai
t'rneTopamrenf'1 ) u . c 303 ROUGH MECHANICAL ,',
01 ofthe prpertyamuseIn b c".atracfir,wthrfeemied ionfiractm,on 304 '— ROUGH ^ELECTRICAL
compact thproject(Sao 70,14,Business laid Professions ca '.)Th Contractor's < 505 .• ' FINAL- ELECTRICAL_
1.ceue Law does not apply t a n bf property who hu I 1 i np�otes the wn and n contracts far 1 i to°wimaG>mmetarca) :Jn milt are - 507 '—' FINAL -PLUMBI'NG
ol
Ct t :L'Ferro, - - e
❑i pt under Sec. B&PCIn,this a,a,un 5013c — •FINAL_ NECHANLCAI
Owner - Date - 1 s -
WORKER'S COMPENSATION DECLARATION
" I Iicmby affirm under Penalty of pefiury one'if the fellowinig Jedamtian.: ^ -
1 h and will.rot ' C nitical f'Cosent atams Ir' re for Worker's
on pen:'C provided fr by Section 37101 f the labor Coda .for the - n'. .'
,od of the k for whichthi pormit ISissued.
❑Ihave d dd reartain W k Compensation haliffunce,.1 accruedbySuomi - FINALED' -
3700 of the Labor Cadle,far the lierforiummen of the wort,for winch this Per n I is o '
issuall MyWorker SC p fr Insurance earriar and Policy numhe'are,
......Nrdcrnl PeliyN, Ipi�o231 MAY..' 21 2601
- CERTIF1 ATION OP EXEMPTION FROM WORKERS ,
COMPENSATION INSURANCE
,. (Th : nonneed net be ca.ancled fah pertain fn hindxd doll¢: BUILDING
(plan l ) Irk r 4"
1econfly that i tile perfortaines,of'he kf h�htlt p :':c d l
shall ,' II Y an,person y nanner.a as to baewnr�y ��nu the Workers'
Comb mu I 'a One fJ�� 9
we B���j
Apphcanf- —//� 12
NOCICE TOA PLICANI If ft 3kl gth C if 't erosion,y Should
' z beton Subject In the W k C p t p not 1N LM Core y nil t
O O forthwuh mply with 1 po lawman thi, irmitsfall he dearredre,mord.
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1
4 CONSTRUCTION LENDINCACFNCY
a ' I herehy affirm(hit there s mGi
cln tarn lending agency for the performance
of the work for which this 1cannit'IS ISSLIed(Sec 3097.Civ.C.) -
•� (� Lender's Name
z Lend,':Addo,"
V 0' 1 certify that I have ad th'.,app1 at n and statethat de'above infloriviltionis ' vo
k•I F^
careciet.1 at t ply with all an,itJ „only edionance,and Safe I' f l -
� C) building construction,and hereby author p oboes ofthrity to emertpoo
heproperty
ly rs] t 66 1tited pr P tY f nspeci n p rpt' •' - _
Fyy (We).9.to save, TdOnnint, adkep harmleei the city'if Cupertino gust
rw Vi 'I abil' .'t J dg t t I: d 1 :which may n any vy t sore tga nit sand
C.1 rZt .Citysogtcnee of the gonig of his Punt
APPLICANT UNDERST�A�1�'DS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGUL1BBiS� A/W
Issued,by. 1' - Date
-Slgnmure nb ApplicmdContmcnr ' ' ate - '
HAZARDOUS MATERIALS DISCLOSURE
RC-rOOfS 1 k
Will the isio al or ra lure building Zaimparttc handle Innrod 1,material Type of Roof
as'dcfned by the Ctpenmo Nlun'epal Cad,Chapter 9.12,airtime Death and Safety �• 'ykyj+� fF i
'Code Section 25532(0)' m ".7 ( 4 q.i,Q
❑Y ❑'N - t All roofs shall be Kpecteil prior to any roofmg-inaterlal being installed:=
-
Will the ppr t or ficalre holding e p' t me continuum”lines iriswhichIf a roof is installed without firstt obtamI inspection,4 agree to remove
With d :Or Ia t '.dind by the Bary Area Air QallyM g t t > g'an
Diiv t❑Y ❑N j - all new materials for mspecbon�rApph'cantpnderstands and will comply'with
alf non poinpsource regulations ' 7.
I Ime'read
' the Tocantins pretendsq l e ' d Chapter6 95 f the
CthfaH-llh&9 ftyCW,S r .25505 5533d255341ad 'tdl
d tcurrently the huld 'feasibility mouth,
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accurate, f Tim wh eh must h t p no l.t e or a Cert'bwt 1 e i+' S I-I�k)1 -m t f� +h
occaP ey� gnature of Apphcanf+�� �` T ,'y=k4,r�u i' �t Da'te' -
Owner or unmonved agent - - Date .. a '" All:rddf eovarmgs'totbe Chase "B"or betterP. .,
A
OFFICE M