00030194 CITY,OF CUPERTINO - 2 'PERMIT NO.
BUILDING DIVISION PERMIT", '' CONTRACTOR INFORMATION. �`y�j ►�;.
t BUILDINGADDRESS: •' t "' - IC SANITARY NO. APPLICATION UBMITTAL DATE
1049.?, _5 ,
. i[My
OWNER—Sr; 2: ;,. /� ' msC�(.� 'en�� . /J�/(/Q N/C - CONTROLN .
PHONE /v.$�
CT >NCINEF.R ' I�a,�(a5�°'TX 75�2[O' r %�1 S!� y•
` ARCHITE
OP I INYO
2
cmi 'ry 3sa. -. 3i9 �,
0
LICENSED CONTRACTOR S DECLARATION
Zm 0, tummy amren that I am Gwnsw under provisions of Chapter 9(co mnenc roe '''Job'Description
Pt m wid,S 6..7000) fD' 3 ftheB Business and Pro@saod Code and yliee
o�< 'f��, 'n full force and effect - -
u3 class 3 It C
w t- Det Co... .t / , /^.�—a�. „��p�/1 ///�/iy��,��T{I'/T
ARCHIT=SDEC ON / ) i0�(V(J', � �aD � z/G . iA✓•^•""'_•
I undersand m pill I sed u p rands 1 I
cerised Pmfexa' I' - 'A
'6 OWNEER DEC TION -
TT Lhe y.dim Chet I em to Contractor L cents.La i'fm the , '2... .'t
p foilawne son (Section 7031172.Z.2'nd Pmf Cade Any city a..my,
w 3 wroth fires a permit m cons act alta sup - demolish, Enterrcany atmcwreS FIr F']OOr Al'ed r /( Valuation -, -
tpnwtoi rseuence also rcgmrm Ne apph tforeuch Perot flee Igimd sum rnt. q4 W /ILfI/A✓)
Net he slcenmd pursuanirNe provisions mf NCCmttu[or'a L¢rnse law(Chepmr9 /'
(w 'ng 't Smd 7000) rD'axon]ofNc B&immum femoris Cita)or APN Number (� ;' •, Qccll ane Type,
'
Nath is axe pt t frm and N haii,for Ne alleged sorption.Any violation of 3 "DOd / y
Sepho 7031 S by any appl cant fa a permit subjects the applicant to a civil penalty of
t ow
five
ehundredd ll (5500)
C] nexofthepoperty y ployeeswith waguaatheir sole comperoatsm 2 t ' Requiredinspections '•�
will dothe work and Neawcturt is not intended offered for sne(Sec 761,1 Business +• `
and.Prof Cade Th C tui t .License Lidoes trot apply lom ow f
property who bu Ids o p N on d h does M1 rt himself o through 6- :t
hisemployees.Provided to h imp aveme t are notintended offered f I
sal If M1 r Ne bu Id g mpmveme t Id 'tui oim y f Pletion t 'l'
pros bit ldcr ill have theburde fpm ng that h did not Wild or repro,a for par a i' n
I. poebofsale.)
i
❑1;Es owner of the" 'n,sin e'IIy conn t g wit licensed conttcmm to Ylo
r comar cl the project(Soc.70,14 Business d profesu Code)The Conuecmrs U.
cense law does not apply to an owiier of propeity whobuilds or improves thereon and /
wimeontrec Ramada p.job with a coronations)licensed punumt m i�e Cottmctas -
Licors,Law.
.i. ❑I rm cuript under Sec." •-B&PC for Nis.6. ,
Owner _ D m -
^WORKERSCOMPENSATIONDECLARATION
1 hereby affirm under Pmaliy of pe)ury one of to following decla7misms
❑l have and will maintain aCieiflcam ofConsrnuo selfmire f .Worker's Corpen ,t
saran"as Provided for by Section 3700 of the Labor Cade.f thepertotmance of the s +
work for which this Permit is issued. t + '• '
❑1 bastion will mainmin Workers Compensation Insurance,as required by Section
1700of air Cole,buthe performance of doe work for which tis permit is issued. -� Y i'
My omansati e 2 end number arc:'- ,•
cam i Y N ' e
CE Inc 1I", OM WORKERS a"ni i a
' CO SATIONI URANCE - -
(namwc nareadtio completed if permit is forum hundred dollars($100) � f a "
si Icmify Nar in the MformexenI the work for which this permit is issued,I shall , - -
nm employ any person in any rommar so as to become subject w Nc Worker'Compcn- _ -
unionLawiofCaliforia.Dais •I " • - -
'j Applicant
NOTICE TO APPLICANT If,after making this Certif¢ne'of Exemption you should
become subject to to Workers Compensation emit,mm,of Ne labor Code,you most, _
forthwith comply with such Provisions a this permit shall be deemed malted. ?
CONSTRUCTION LENDING AGENCY �' " "' ' - O
o I hereby affionNeitemisecansweuon lending agenryfor the performanceof
-Ne work for whmh ti pemn is issued(Sec 3090,Civ.C)
Lender's Neme
Lenders Addies
Lal I cantly than I be ve read this'ap'li anon and ante tat the above information is s' -
G
correct
I agree to comply with all city and county ordinances and stat laws redoing t e ..
z ,.building construction and hereby amM1onze represcnrtmes of thiscity t,enter apo the
V •above ma.ti.ncd property for inspection purposes I +
(We).gree m save;mdemNfy and kecP harmlrx the C ry f C pert no agmnst '
4.) liabilities,judgmenn,cxnand eaprnua which may in any way ganxuaid City
,y W in<onsc9mexe of Ne Brnting of Nis pemii ' ^ ,`'
F p^ APPLIC I UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
z, SOURC;REGULATIONS.
ignatu o Appli dComne - Dole
HAZARDOUS TERIA DISCLOSURE „
• WiIIN pPlicent or Tamm doing xcupent eorc or handle hazardous material, Re-rOOfS.
as depned by a Cuperti M n ip.! Chapter 9.12 acid theHealth and Staley a '
'code gecnonzss3xta) Type of'Roof '..1
❑Yes N ♦ ., k
Willthe appmcant orf tum buddi gacupent usecq ip t rd,iaets h h
All roofs shall be inspected•prior to an roofing material being
emit hazardous air coniarn iianta ax defined eBay ArceA Qnty Manegemm installed Ifaroof is installed without first obtammganmspeehom
°`° " I'agree to remove all new materials for inspection .Applicant
z ❑Yes [px< , + d
I have rod the hazardous nod nnsiryuirtmenm under Chapter 695 ofte Cali-. Un tar rods".and will comply with allnon'point source regulations..
s ... form.Health&SRety Code,Sections 25505,15533 end 25534.1 understand thin if the ,17
buildingdoesnmcurmndymveatenen4Nititismymc nsimiitymnmify teaccu t
oftemquireir,eiiu wh'h-ust be sun pnaim rssuence ofu Certifiwm of Occu cy.
S nature,of /pplicanr Date 9 ,
Ow ror eutonzed eget:.' am 9 .7, •. ., . . ', .I''. .': '. ,. ',. ,. - .
6�. Al]ro f coverings to be Class"B';or tiette'r
°`'OFFICE ;