00110123 CITY OF CUPERTINO- ., t
_ nutLumc DIVISION': CONTRACTOR INFORMATION
PERMIT
•. -BUILDINGADI)ER ssU1 .,BARNHRRT AVENUE" - RaAR--DRA'IN PATR_(-)L PERMIrw3x1a1 I,01p3' .
OWNER'S NAME: ` ' APPLICATIYA Uy.FXsi
EVA ZENO 7',701 S 771A. .;t' f, WYrc'Q11Z0
11 PHONE: SANITARY NO, CONTROL NO.
"
(A08) 989-6005.
O ae Z ARCHITECTIENGINEER: - ;;y ! BUILDING PERMIT INIU
OW❑ "BLOG 13LFC'I' - PLUMB MECH
a v fa IL L=l IJ L^=1.,
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t- LICENSED CONTRACTORS DECLARATION Job Description
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OZ,", In h1 Irrn thatl licensed e p t. fChpl 9( e g - "
wins r lot ) rD nl-e lin Eyy,a/P' e» li sFWER,-LINE' REPAIR ND -rvlo—WAY HOUSE '.CLEF
a ¢ Lic IIIy -
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OWNER-BUILDER DECLARATION
WM io It by affirm that I pt I ffie C t Lierawe city
for Wo
toll
Q b (Section 9UJI S H ❑I f Cd Any-and is mer Y
Gor
w II n p J Ih p Y t nurc .. .
prof I I. l m ppT ft is g d.lmment
tomo 1 aaea l Sr u d p nn c t t - 1 I (Ln pter9 S Ft Floor-Area Va t
from nen s e with Seedon 91X10) the bra
m t of the Bus ne and Profess ani Gale) q' I_
or that he is exempt therefrom and the bests for Iho alleged exempdan.Any violation
of Sedan 7031,5 by any applicantforap athj cL the appy flacivilpenalty ,
of nm moremat 1 ve n e e a Dari(S50o) '"APN Number - Occupancy;7ype'
375Q19 Z14.i.. 1710
DI,as ow."Eii
a property, yc ply lir wages adE their sole venapparration,will do the * d fire husband, act intended ,,o1puedfir,safe(See 7044 Re
Retire,,ar of propvny wti nnaiae �Th,p;,el Ht ',License
whir �.�en work ln'l,.'In _ 1(JEI .—' °aEWERquirecJ.��sl�Eekions ,
or through F n employers,provided that such 1 veal t: 1 mended or R w .
offered for sale.If,however,the building or improvementis vIld within oneyear of 202 'UNDERFLOOR PLUMBING _
complctioa.lheowner-builder will have the harden ofproving thus he did not build or
impmmxm
rovarpa000fe), 301. R6UGH,'PLUMBINO
U 1,as uwecr Lf )I,pmperlr,am exclusively ecarowllag with licensed eontdtato..to - 302 TUB- & OR' SHOWER
Lmonmcl the prgpact(Sec.7Wa,Buains,and Pr..cefons Coda:) [he Commemr'a -
iced,Lawdo,,aot army man owner ofprapertyww,hWd,orimp....asneaus , 50?_ — _F•INAL" PLUMBINGENERGY
and whe conmaels far etch proJe-c'Is with a conmacan(4)lioeesed pursuant la the
Cmtlraelerauaan�Law. 50,6. — GAS' TEST
rUlltm exemptaw;rsa. ,B&Pefor this re,taon 507'— FINAL PLUMBING
,Owner Date
.. 'WORKER'S COMPENSATION IIECLANAHON -
Ifiencley afinJ P ItY fp 1 Y ftl roll ,drefiri _ -
(�.011 J 'll vitamin uWtfa f Confivalt If for Worker's. ..
.
Cian"'asition, is provided f by Section 37101 al the I her,Code. for the ..
pufforroduccul lire work kr which this permit k isteed, ,Cl Ion,e and will maintain Worker's Compensation Insurance,as required by Station "
3700 offma Term Code,for the peffirmarice ol,thework I which th',FEE is - -
awa.My\V r' Compensation Insurance r�t�PyI YQVrn6e 60 O � 9
CERDFICNHON OFF.XEMPHON FROM WORKERS' "
COMPENSA'110N INSURANCE t
(Phis section necJ col be unnpleled if the permit is future hunared dollms - -
{S100)orlc,cJ
1 anify that in the perforinwtce of the work for which this or I I,issued,I
-shall nm employ any person in any mumner'so as to beeonte abated m the Work,, n
Compensation Lawsnr California.Dale -
APPlieard _ t
NOTICE'PO APPLICANT:IL after muka,itis Cenifirm a of Exentainn,you nhould '
•hamate mbjecl m WC Worker,Cmngensnlion provision,of LahnnGtde,you at "
f nhwith comply will)weir provisions ar this permit shall he deemed revoked. I
Z Ir.
F'tiCONST RUM ION LENDING AGENCY t "
a ' ± I but aftcot that theran,a Enantmedion Iturdan,al,ar,far,the pnourm ace
W of th k for 1'ch Ila,permit k sw.If(See Li C)
Writer,Name
z Lend Address .
1
'Q6W.)'Cr�QV.]+7 •ltsa ' iprythat five 'Ill : 1 el.t I"I h f 'to't is
correct bripard to With citY'dual Courtly eadinduCtb4ad State totaling
building a r a: by entirep rd - dh,city
tmcmu pon
he db Iparty p t P P ':
Wel g t s indemnify andkeep lamthe City of'Cuperonsingicaust
liabilities judgment, 1 a p - whichmy nany we, hxt.ad
sq cote ofd gD rag fLm
APP ICerp UNDERSTANDS ANDWICOMPLY WITH AL ONPOIT
-Issu. 4 dby:ol TAFT Ns
9 P'(
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,.
�
Date ( L-
ral e of Appl canJC tractor - , Dae..: Re-roofs `
HAZARDOUS MATERIALS DISCLOSURE
Il me Epp1'- 1 lowne b lti g p la nhandle N aerial Type Of Roof
as defined by the Cupertino Municipal Craft,Chapter9 12,m 1 the Health and Safety
Cute, Yes
n 25532(u)P �' El No .
All roofs shall be inspected prior to any roofing material being installed.
Will lir I t future building "'
rp 6 p 5 y p 1 d :which If a roof-is installed Without first obtaining an inspection, I agree to remove
smith rdcontainmentsa"den di Bay Area A Quality Maragcnent
Dist tt all new materials for inspection. Applicant understands and.will comply with
°Y °N all hon point source regulations,
y 11 andthe J d : t,l l i' ens milrChrt 6.95 of the
iSafety
California Health& Cnde 25505 25533 and 25594.1 unavrnand that
if the huildmg doe,not cvriently hmcalmtan6 ihnt it is my raspnnciM1ilily nt notify the t
occupant of the myufremed,which most be met prior to issuance of a Cadificvm of" ,
I( 2�` �• " Signature of Applicant _ Date
aeo"agent -^D a= ', - t All7oofcoveringsto�beClass B"'onbetter
v: s" OFFICE ':r
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