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CITY OF CUPERTINO '.
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CONTRACTOR
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BUILDING DIVISION PERMIT `
INFORMATION:'-
BUILOINGADDRESS:
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PERMIT 'N
4121.ct?IOG7::
1,0882 8,BLANEY'AU
OWNER'S NAME:
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APPLICAis N..SUR, la7C ,_ y,00 ,
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INTRINI5IC' VENUTRES
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ONE:
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SANITARY NO. - , CONI ROI. NO. '
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ARCHITECT/ENGINEER:,
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BUILDING PERMIT INTO
BLDG ELECT PLUMB NIECE,'
LICENSED CONTRAC (ORIS DECLARATION
Job De scription
' 1 hereby )titan mut 1 am ,accused nines prod of
n, Code9 license
Emission,
[D' :'m 3af NCB -: IP f Code.: ay Lecnse
l Forearm
sur deft
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ELECT J—BOX. -
1,inf
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License Class —e„1nf
Date _ ♦ � _ 6 /ie C air, mus /1aO¢
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• AT2C4{ITECT'S DECLARATION-
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l andmemnd my plans shall teased ns public mcmds _ e
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Licensed Pf.. al
OWNER -BUILDER DECLARATION
1 heMay alliin that 1 a n oxcrom trundle Comma r s is ecase Law for the
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following mason. (Berlin. 7031:5, Business and Pmfirsnions Cone; Anj city m,nunty
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Illicit hcgaire, n permit to cvsnsrruef, alcor, i,nprove, aerialish, or repair city structure
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tee
e.,plawal fmchpanni) la flensigncd,mmnt
priortoits issuance. also mgaimslhor
- - ' Sq. Ft. Floor Area
drat he is kinociltsir,rand in Ilay,ansudia,.1 he Contractor, License'Law (Chafer, 9
c engwth Section 70010 fD'v" n3oftheBadn mdPufes ,.,Code)
or mu he is exempt therefrom: unit the basis l r the alleged exentptlon. Any vanlntion,
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of Section 90315 by", applicantfnrupermit . hjol, lie "pplaun a civil punchy
of tm ..ire m,m rose humaltoddollons (s5AB .,
APN Number
Occupancy Type �.
3(,9330 5„ ISS
❑ L as nwnor ofrhe pmpci y y m memplayccs with weses as mein sole ann.mortar,
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- Required Inspgct�Q t
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will d J 'k, amt he simulateh,,no, intended or offered f : at, (Sec 7044
Bui,incii, and Profession, Code I he Cai t 4: License Law does it.( a,rd, to an
'fproperty Wn builds p thereon,d n d such work lRmsell
304 '.ROUGH-ELEC1KIGnA•I_
ow
rthrough h. ply provided tl t. h p is - t tnded or
ofleruLlot vale IT la oxer, Bae ht -brag � improvement ,In. wathn one year of
v - e
,.501 — FINIAL_ EI_E'Cl RICA,_ E;NIE:RLi1'.
omplainn, the owner -hander will have the harden of proving that he dad not balm or
tnpmvq fn. purpuw ofmtle).
_505._- FINAL' ELECTRICAL' ..
° 1, us owncrof the pmpeny: uta aScluswely mntmaing with licensed emnaut to
construct the project (Sea 7044, Business and Pml'essims Codo) The Contractor's
License Law does not apply to an owner of property who build, or improves thereon
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.and who contracts fair such prnjeciti; with a mntraanr(s) licensed puramnt to the
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Communal'License
°I am esefUld amde, S,, - 13&PCto, hl
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Owner Dot
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%WORKER S COMPENSATION DECLARATION'
I he by anion aid p "lry 1 ) mar f,hc following d c ins,t
. 1 ave and wall maintain n CeYR"t of Consent m xell asumfor Wairkera
ky
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lnnpensataon;, if, provided I'., by Section 37A1 of the Lahor,Codo, fir the
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pafmmanee at the work mr which ,his pcnnit is issued
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° 1 have and will maintain Worker', Cnnipmuadnn Insureaca as regained by Section
3700 o1'the Labor Cade, for the pedi rmnnce of aim work for which this penuat 1,
issued. MyWorker'sCusurprossation insurance carriers Palley �j her/0ur�my;'
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Cnruc,::5 ') l 640 airy Na.: _ ��`� •�� -
CERTIFICATION GFUXEMPT ION FROM WORKERS'
-' COMPENSATION INSURANCE.
(I'his c nom aced nnh be cumplamd if the pcnnit is for one hundred Jallurs
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S 100) of loo.)
I certify Ihw is the performance of the work for wlJah this permit k issued, I
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shall not a ndry : I ....... n day manner sit as` to thei:nme subject to the Woh kers
Competsadrnt Laws of California. Date
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Applicant
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N(HHCE,TOAPPLICAN'1': Iq nOer making tuts Cenlfmte of Exchnptinn, you should
hecnnio subject to the Worker's Compemutu pmvmatnsaf It, Labor Code, you toast
forthwith comply with such provision, or chis permit shill bedeemnl mucked:',
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CONSTRUCTION LENDING AGENCY
I hereby affrm that there is a construction Lording agency forthe pcdormance
work which this permit is ixsuua (Sec. 3097, Civ. C.) - _
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eesme
Leader's
Leadm'z
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. Lender's Addre§s
Adde
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Ir ify hurtlh e re"Itis', p, fl,rion 3 I Irm thandre tairwef .. nation 1,
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,.'em. 1 a' t ply winholl 6,arid ounlyondimemess d(am I t g^
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mbuildup construction,and hereby authorizerepresentatives tfthiscty U) enter upon
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the ahave-meramard property for inspre ion puq......
- (We) agree m sove, iMemnify and kmp humnms (he Cdy of Cupertino against
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Ioannina, di expensef ch ma, in any way resume again said
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Ci n: q ercesof.at g 8 tis IIn
A LI N1 LI F.RSTANDB' WL�PLYWITHALLNOlPINNTv,
S dente
Issue&by: Date
. isnnmre of ppfcantlCommemr
Re roofs • - "
HAZARDOUS MATERIALS DISCLOSURE -
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Will the applicant I Li bildmsceaupan,mm oris JI 1' dusmt al
of Roof�•' -
,ta 11 enym c v n pal crab ch.pmr9lz do Health ales tty
,`Type
Gd Smtna-55320
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All roofs shall be inspectedprior to any roofing material being installed.,
Will oieapplicant mfOiuchnildinoccupant u,cegrtimncntmaevi,e,which
If a roof is installed without first obtaining an inspection, I agree to remove
Chair hazardous airconta.... rr defined by the Bay Area Ar, Quality Management
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all new materials for inspection. Applicant understands Bind will comply with
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CI Y." No -' � ":
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all.non-point source regulations. '
I have read the hazardous nmterml, requlrcmcnL under Chapter 695 of the
Callbrain lleahb&SafetyCuda,Smtinns25505,25533nnd25534. Iundersttmdmm
ifthichaildingdoc,n t,anomly ho,cliaturna, ttrt itismKa,mobalit,t notfyfh-
Dept tis lire tsxhri muj� ell Inc faC t of"I
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Signature of Applicant h - Date
All,roof coverings to be Class "B" or better
ow orafmnrixcJ-agent Data
OFFICE