00090179 CITY OF CUPERTINO
AUILDING DIVISION' PERMIT^ CONTRACTOR INFORMATION:
.w BUILDING ADDRESS: PERMIT NO.
OWNERS NAME:'r- APPLICATION SUR DATE
PHONE: . • • - " SANITARYNO. IBI r
ry 'CONII(LN).
• t i. r11 . ..
µT^I O O ARCHITECTIE G R !";. "• "�� •_ ; BUILDING PERMIT INFO
.BLDG ELECT' PLUMB MECH
F Z - 7 , =1-, 1 I_I ' CI 1=1-
66 _ _ f •
LICENSED CONTRACTORS DECLARATION.
z o h b Job Description' '
tion 70effrm thtl ofthef4 I p neon Cl npme9fwnmwese f -t:d, tins t 9wB1 on D' a nnesa IP f cd ,e any license
- - .
qS it tall force d•Ifeet.
S�a L'e Ins
'O3aH Dm cnnac or C " .. .
AKCHI fI C f S DECLARATION
ton,
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ad J ,d h ll6 used P bit ecod, REMODEL/ELECT'
c5 Ltc I P otese'onvl - 1
km . 4 OWNER-BUILDER xemptDF.CLARATION, _ e
-w c m I herehl.:firm c, 1.n exempt n m Contractor L L for the -
F"ZQ toll g - .( i 9tyU5 finlr dprofessions Cd Any city or caunry
€O which ts Permit r .S t cap e I list, repair' y.t ewm
F�
oriental r o y pr applicantf hp n II nsignedChapt em
— 'morn r tip . St 0 p to cal Contractors iL 1 (Chapter Sq.'Ft.. Valuation'
(mot he is bwth Sen' ]OLID)ofDevii of the 11 1. f 'Godo) ,-
rSectionaexenpttleean f dth b firth objects
pr An, Infan ` '. '
of Scel'nn 903156YaY red nits 500). hl ue lhcappl uoneiv'I penelly
onset tnamman rren lee collars($5wl APN Number ccupancy Type - '
_P 1.ns awwork, pr p p y p1 y dr age' 'th compensation,
',,If d S he
k a d he t y Canbrardrd r offspi 5 1 (Sea ]1144,
Business and rr las
socip,CoencTlic Contractor's U 1 cardassom ppy to an " Required,lnspectioUs -
wnr rpmpe tY Wh h I1 y d f h d ktim:lf y
orthraiiim hisown PI y .poisoned that s h iu t S intended,,,
'
offered f safe if,h o b ldeg P ld w:lM1 n ane yc. ,r c2Er551Z .'00
omplei a t the owner builder will have the barden(if poising for,he did not hu'ld e, ..
mprave for parpoee car cvlol - «•.. „ '.
y
❑Latnwna<<,rmepmPeny.an,nxelasirelycantmningwltbrnensWcnnnnnarsia 304 ' ROUGH ELECTRICAL" t ,
constmet the project(.Sec.2w4,Business and Ptnftsomns Cali The eomracto"e 501 . FINAL ELECTRICAL. ENERGY."
License Law does not apply to an carter of property'who hot do or ire 'raves thereon, -
P P Y
P
mW wtia r,Licns for sten pra;ccta wile a nmrmcrdrcs) uent.eJ pamaanr,ra t1,n 965. FINAL ''ELECTR I CAL
El I manoi4 Licence Law. 'n -
'OIataexemptunderSec. B'1 t'Cfor this reason
•• Owner - "' Mare ' r
WORKERSCOMPI: AT
NSIONDECLARKII'ON •' -
4n•' r
I fairly affirm under penalty of,perjury one of the following declarations; ,. 2
❑ I have and w0 maintain t Certificate of ConsenttoIf Insure for Worker's' 4. - I: •,-
Compensation a' pan,bdod or by Section 5900 of the Labor Code, Er the
performance r❑ work for h hlh:p t J,
Cl I base and ll 'nS Worker's C p r 1 a refound hy.Section ,
3900 fm b Cod for tile performance t the work1 hich this permits
issued.My dorkeri Compensation lnnoiranCc earlier and Poly reamer are.
Carni, 1 1 PuliysEn: c
..
CERTIFICATION OF EXEMPTION FROM WORKERS' , -
COMPENSATION INSURANCEis
g - e
(no'sector,need"nor be completed ifin,pcount is foram hundred dollars'
(51W) rlesc) . . -
1 certify that in he Performance ofthe work for which thif,parer is ,sued,1 - -
,hall nut employ any person in Smy manner so as m became suhjed to the Workers'
Compensation latws of California.Data
Applinant 11 . & F I .. a -
_ NOTICP.TOAPPLICANT If,ahelnvking this Can'hcale ofLvnnati,on,cauld on
Z hee,ne suhJcer to thaw kf:C tpmanl p ms al the LabnrC Ne
you must
Q O forthwith comply with Iowa fareAllial this permit shall be deemed revoked
Z Z
CONSTRUCTION LENDING AGENCY-
Ih b} ffinnWill th :r f I dyagenyfr the performance
cil 'd.rr lotltm pe cat is issued(Sec.3(so Cie.C,) -
* z 'Lands,Name
Lenders Address - a
Un
sari lm
y ,, i ha d thisf - m
pplic and but the h 'nit' t - - 1 - - - '
correct 1 agree to comply lh ll iiy an t county ordinance;and swtelaws ml't ng '
0 �1 to building mensvummn,and hereby SThorize repassenmtives of this city law=upon
ty W the ohnspearrandemedp PrtYf 'P ectioripmptests.
�yy (W)ag to...c;mdoularrify„ dkp lvmis the City fCpcu "g" st '
it pit
liabilities,judgments,cosS d expenses w hich may in any way oiccmc against slid '
6,7 'City iii consequenceof)in granting or this permit, P
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.PO1NTp.
SOURCE REGULATIONS. Issued by: • Date.'
slsgamra arAppre�n)cannnemr • , Data .'Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
•applm _ 7ype Of ROOF•' 'i•,y
Will the refTSbtldng 'ep 4 t. 'hadleh end• 'material f
as def ned by the Cupen'no Municipal Code Chapmn 9,12 and the Hwhh and Safety -
Code Section 25592(,,)'1 �,.,(
DY �” - All roofs shall be inspected prior tl roofing material being,installed.-''
Will the pp1 t arfairmhaildingoeetpe,ttsergalpnen devices which
If arooflsinstalled without first obtaining aninspection,lt'agreeto'.r8move
,mit l d s:i coon tin i defined by She Bay Area Air Quality Management
Dobal? „+, ,all'new materials for inspection" Applicant understands and�will comply with
❑res •all non=point source regulation s., -
I h e mud the'reaction,materials q it rte t and CI epi u.9,
d the _
Cvli[omia Health&Sety C ode,Section,255115,_5533 card 25514,I t tdersmnd th,,t �, ^• •'' -
itthe building does nut curremy have atennt,that It is my reaponab Eryna oar fy rl � '
ucup t of IA` cots whrJ tit Sp mSssS n IaCen'r cat L 'r
Q"" f�a//? jr l nye. ' Signature of Applicant_ Date
-Own aathoneedag Is Dale - * AII•roof coverings to be Class'.`B' or better '
OFFICE ,+