01040021 CITY OF CUPERTINO
BUILDING DIVISION PERMIT, CONTRACTOR INFORMATION:
BUILDING ADDRESS: - PERMIT NO. '
1.0950 'N BLANF_Y AV 01040021
OWNER'S NAME1, , AYPI.ICAI'ION SUIT DA'I.E, ,
—AI_ 04/05J2001
PHONE: - SANITARY NO. CONTROL NO.
0.7. ARCHITECTII:NGINEER: I - .. BUILDING PERMITINFO
z ❑ - • BLDG EIIECT/ PLUMB MGC
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LICENSED CONT'RACTOR'S DECLARATION
5 a I heron niter tile[1 am ficemrd Inner of Chat y Nonlinear, Job Description .
OZ z_ r pmvi,ions Chapter g
with Section]aNp of Uivixinn 3afthe ltuxinev an C,We.and mylicalx ',
a y is in full force an 'R_ g�r�
�o� Zd ic.I f e"In Y�(I AC PACKAGE UNIT INS ALLATION ON ROOF.
a a .ice C1. ..
3 a Dare / conuacn - _
�
ARC
to fLC'I"1 UrCI I(,u�0 I d r Ainy"I'd,.I�IIh nal :pill' cards •. -.
deyy} j
Lc d P fissional
°' Uar NFR RUII DI R DECLARATION CormaON '
'= I hereby.S bar I p[ , the C [ t Curio: en:c ty for the /
t 3 a full g rtt (S t ]031 5 B: el P f n Any city manly I�
.F C which q M1 I I consumer.are, p d 1 bard, ny oral
r�a aCa prir I I a 1. y .Iliapplicant n f h permit 1 signed element
barb l II t to the p It c r I I L Licence9 Sq. Ft. FloonArea Valuation
......mene 1,with See a 17001)of D Y.on 3 of lie Business and Pro)rations (de)
or Thar he is exempt therefrom and IIIc huxis lilt the alleged excmpiera Any violation -
ml Section 7031.5 byway applicunl for n paten[subjects the appllcunl n u ,,it pens)), I VA kA 171 M
of.01 methanfile hundred drums(s5ol). APN Number Occupancy Type
O L as owners the pmprny,or my employees with xli es as Bud, ole comnemution,- ,i
will thek ss thet r [intended a offeredrr.-m(S l 7044Required Inspections
Businessd l kai -ild 7th Connector's L L not'.plyd an
fp pay Wh, bu Ic folded:flrt ande,wh, dss zest wekhnmJr - - - - -
nrvllreclfor snwt,rnplnyeeIt,Nuldenfl,ulmuoevereonkol nrveltintendedor 204- — -UNDERFLOOR FRAME f
...fere))Period.
liel.It,however, will
building a Impr„vemenf n old he did one build of "
mpletion.pal'onufhnfiderw;nha:'r dre nntden or orosmgrnaf he did tee build o` 301: — ROUGH PLUMBII�IG .
improve for parry)>r or sole.). .—. .
-
01.as owner of the properly,am claclusevely contracting with licenews]contractors to 30.3 — ROUGH MECHANICAL '
onswct the pnljeeeds
l(See.]Bk4,Blie.,and Prafmils CoalMe CmargcedC, 304 — ROUGH ELECTRICAL
License Law does not apply to an owner of prepcny,who but Ids or torpedoes threaten,
and on.correct.nn.such projeel,win a eon[meonsl bcar,ed pueuart u; a 505 — FINAL ELECTRICAL
ctnnrcamPa Ltc're'd Lu'. .
❑l am axmnpllielcr Scc. ,B&I'Clormis_reson 507 — FINAL PLUMBING
Owner Dale 508 — FINAL MECHANICAL
W'ORKER'S COMPENSATION DECLARATION .5:14 — FINAL PI.IBLIC WORKS
1 hereby off nn ander penally of Perjury one of the w1kevin,decleammes:
�ltl 1 have and off ineurnain a Caddwate of Consent In will mare lin Worker's
Conon,al tee provided for by Suction 3700 of Ilia Lubin Code, for rhe
e rforn ence of he wild far which'Ilik,nnif I,t„ued. -
❑1 have and will o lneln Worker's Concamnn Insurance.m rc Zid b Soman n s
3700of they.M,r���iiiNe,for the perfommncc of the work(ter which y
this permit is
i.wed.My J''OTZ'rtion lnsumncecurn li be arc:
Cartier ••1 Policy
CF.R'rl19CA'1TION OF F;%EMI'I'ION FROM WOHKIiHS'
COMPENSATION INSIIJYAKCT!�q SLG 0 .
frill,seefinn aced dill he conlpleed it the plant)is fat�/one hundred dollars
-
($1(m)or lens.) - -
I comfy that in the Performance of file work for which this 1conit is issued.1
shall not employ any person in any moaner so as m hewer subject u1 the Worker'
Compe...tied Law,of California.Date
Appltcam
NOITCETOAIIII('ANI If ft k ,fi'sca'l to mfr apt you should °
bh,1 O h N A ( 'f I i, Irl Cd ) ntsf -
Q � in
forthwith dangly with such p evi.v tet.or 0 pent i shall he deemed retaken.
F" 7) CONSTRUCTION 1.13NDI.NGAGENCY
> 1 helchy nitiml that Thee i.a.onslruclion handle,agency fur the performance
of the work for which this permi[is issued(Sec.JOW,Civ.C.) .
Q Lendds Name
Z l.cnder',Addrexx
t..1 I army y that l huveond this ppllaaion and stere that lbe nhnve Information is - -
Lr. Est oorrcel.1 agree n1 Comply with all city;,at county ordinances and state lows calming -
6) :o ns
uilding enloainn,and Ill inalunsc repesmmtivmol his city In air,upon -
�. the ibme-ne,mimrtd mu,01 for iml,eaion purposes.
E^ 6
(We)agree In save,indemnify and keep haedes rhe City ill Cupenmo agninsl
Ln liabilities,judCmenn,costs and expo nen which may in any way accrue against said - -
f..) Z City in ono ditumo,rf the rimming of this permit.
A 'LICANTU DERST NDSAN WILL COMPLY WITH ALL Nr N INTI t�
s f C Ito .. Issued by: Dale
r/�1}/111} 0 *' G
goof o App�41HA.ARDOUS MATERIALS DISCLOSURE e Re-roofs -
WII rhe applie mor fume huilAing«cupam ane ter handle ha drd.ma malso.1 Type of Roof -
m defined by the Cupedino Municipal Cede,Chapel9.12,and rhe Health and safety
Cade.Section 25532a)"
OYex .0 No 'All roofs shall be inspected priorio any roofing material being installed.
Will ha
icaphcallorrmmehanding,eaprnruse eyrlpmem'ordeviceswh,h If a roof is installed without first obtainingan ins ection,:I agree to remove
"\ emit hazardous circonwnatnumea,dcOneeiby he Bay Area An,QnnlryManagement P g
Dntdgt7'• - all new materials for inspection. Applicant understands and will comply with
0Pc` El No
all non-point source regulations.
1 have mad me hazardous materials requirements under Chapter 695 of the
California Health&Safety Cede Sections'5505.25533 and 25534.1 understand that ,
ifthe buildtn,dtc,not cumentlyhm'e it lenam,that it is my responsibility to nmifythe
cupeat of the 1. iremefns w tch runs[be met prior to issuance e a Ce iheute of "
ova ancy.
� ,9Signature of Applicant Date
Tw aror amtniTdalpav - eat All roof coverings to be Class `B" or better
OFFICE