01010085 CITY OF CUPERTINO
nun.mnc DIVISION . PERMIT. CONTRACTOR INFORMATION-' "
BUILDING ADDRESS', r ,y 'r,' t - a - "PERMITNO.
OWNER'S NAME:, - APPLICATION SUB DATEy i P
ry ri
,PHONI: .. t SANITARY NO.^ CONTROL NO. -
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µ^a00 'ARCIi1TECT/ENGINF.ERY BUILDING PERMIT INFO Y
- BLDG ELECT a PLUMB MLCII ..
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LICENSED CONTRACTORS DECLARAI ION ' +
o� I beirel,G mO C5N, ' ' fOrion l r'n:d p :' 19¢on license g ' . 5 Job Description
wth5 t7a ) fD soV3n[IM1C Bus JPrksina,0.lcanA ny iec se
:fit Fall f `arddlecl
License Class «
3pREPLACE WATERHEATER.'
Dme C t n ;
ARCHIIECI"S ,
DECLARATION- S
El 01 undehxwnJ naY plaow xholPbc nmd as public records - -
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wt00 Ice IP l l - I•
OWNER BUIL DER DFCI ARNHON
XI h fl II I I p r theContractor's 1 L 1 tl a .
C < ILL so 6 scentHl 7031.5,B J. f Code Any city county
a2❑
Prior
t I .. p 'u t + 11 np eJ I'.h P YI n
�y P n t I Jt isrl' I tn 1 n ib s e I t imme ,.
thathe is libeiiscidI t hile,provisiorwofto c t ,t Libon,c 1 fussier,
tw S Ft. Floor�Area-
p 9' aluation
orTh gx'th Seu urn an fDivlsi 30 fie Rsnu: IP f. ' .Calc) ,
only l h 'rapt the - d o bus r ali the xeical n'A ry v olmion
♦ofO t 7031.5byY tf P t ce'tM1 applicantIcivil" peatnllY - _ _ ,+
am r n r hundred d a 'iswo) - - APN Number ,Q�ccupaHey Ty-pe,
01, fJ p o11 ,perly rlaycradoy 11 g: :th ' I .aean, _ f 11
will d he k d flu,Inaction': I unleaded offered f (Slid 744
Blivires,end Pact...ionic CadCadi The Couldoi License Law done i I a,l,In an „ eCl Ulred Inspections
own fp I ty Whoh Id - p es lM1 and wh do 'n workl. If ^ .
orthroughhis ply .:p vJpl ti t: A P t ut dedor ° «
offered for este Ir how ver me bald ng pravcnnot v Id w min one year of 502 F I NAL 'PLUMBING ,ENE RGY - -
• d rPlellor,Ina owner-Walmer will have the burden or proving that he riddle bund or3.
impn,�erorPamoxeorsaiei . . '` 50E — GRS TEST '"
El 1.in owleriefn fnpny, ul :vlY contracting withf e cout ' ' 507 ..— F•INAL PLUMBING ' .
- cousuract theProject(S7044,Bralarro andPor. Poll 11 C I' urs . .
License Law does notapply pply I an owner of furriery who hands or hiptn,es Priced,
' -
and who contracts for such prnjeck`wilb a contmemr(s)llcenaed Pension to the - -
a C,intraher'.,License Law, . _ "
❑I am esnnpt under Sed.-,,B&P C for this reason - ;y,•, 's
Owner Date '
F-N
WORKER'S COMPSAI'ION DECLARATION.
IM1 by aft J Penalty of Pel Y 1Ih followingJ .
Li _ t,v
e
❑ 11 will nuaindain.CIrtea1b,'of,ccobeirtmslli n- f Ww,a +.
Coral salon us provided for by Scu on 3700 of the Labor C de,-far the _
I r flhewod),forwhichthls tia,saoul.•.
pee o mm�cu a prsmt
❑I hwe and will maintain W..rkei s Cnn...ronlon Insurance.as re,bired by Scroll,-
3700 of the Labor CWc,IT..the Perfmmvnce of the work fur which Ihiv penult is
kneed.My Weaker s Compensation lura'nce carfe and Policy suraher are, - )
Currey: Policy Nn
CERTIPIOADON OF,EXEMPTION PROM WORKERS b "
+ _ COMPENSAHON INSURANCE
(This
-
(Ih i Iced and he completed if the porn t'a for care handled dollars - ^,
s 100)an li
v• `• leenfylmny persperlbrir, hadtlhe,n,rk fadullJ'. ceroids Worker,chap nil olion L any person in any manner no m Imhen,me xublen m Oin Workers' r -
G,mpunwninnLuwunfColifarnia.Omc
•. APPlicanl _ , i•
NOrICETOAPLICANI [Carter nialkingth:C tier fL pt yu.hould - r
Z ben n hj n the W k C 1 cn I P f Ih Lah C de y -bust
�Q7 Q fonh th ply will.suchProvisions or J'apvntshot]be decrated revoked.. - !'
,^nr� e CONSTRUCTION LENDING AGENCY.
a.' Ih by ffvm tl 111 mxW f d gageany fur the perlbrnani
Q'
Lif the eaders N.f i tch it Pe a' cared(S .3097 Civ.C) f.
V - rne
1 certify th tIha dIll application and swou thatthebove infirrantradie - • '
W F corn". I grou to viand,liffiall lity and local, Barriers andada f Int ng - s -
'0 [�
IT heath ge n.hiludi a, dl...1,z lhnr ice bc, widahuc,.1 this city to child neon
the ubnve memoned Pnpryf :oicf ED: .r!
y
(We)agree lo act. addrarly andkeph -nales,d,Cty ofCriri in, 's'
Vt .bent ties,j Jg t: is - J disperse,which nay in dayWay a rue agun't s tad -
t..7 '� City lenWaetcc ftha gOrbla,f e's perm - v" ♦
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT db
• SOURCE REGUTATIONS. Issney. Date
Signawre of Applicash CnnbeconDale. Re
HAZARDOUS
- a HA9ARDOUS MATERIAIS DISCLOSURE
Will the applicant town,building old ria t acre or handle hapfirdea,h,aterial 'Type of Roof
us def ed by the Cuperia o Municipal Code Clasher 9,12,and
me Health and
Safety a
Code,Section?5532(a)'r .# r• .
❑Yes 71 No . All roofs shall be inspected prior to any roofing material being installed. `
Will(he applicant or Carol,buildingoccupar,inesqOlonent ordevice,which If a roof is installed without first obtaining an inspection,,I agree to,remove
emit : r contarrt: : kf sol by th Buy ArwA' 0 a I'ty Management ,
Direr i - all new materials,for inspection. Applicant understands and will comply with
❑N all non'point source regulations.
I have end the hapaNan;loodenall willualcui order Charter 6.95 a the
Cffliaarrdafledljr&SftyCd Selfiial,25505,25533 duct1 d :cndthat
if the building does not currently haven sew nililit is my responn'b'llyn ratify the -
occupant of the a r
on,io ' hichmnmhe near rm isan I C fficneot -
occnp y. - - Signature of Applicant _ Date '
owni n11oraod6gent One All roof coverings to be Class B"oc better- • � ''�
OFFICE /