00050192 CITY OF CUPERTINO ' • • ` - `
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION .'
BUILDING BA_%": BOLL I'NBER -'RA - FALCONE 'AND SNYDER C TW)
'OWNER'SrSBNAL'IL MODI ., 650 LINCOLN AVE APPLICATION SUR MfO -
PHONE:. SANITARY NO.
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O z R ARCHITECT/ENGINEER: - -r-. BUILDING PERMIT INFO
l40B)G�9 —9705 /• BLDG ELECT -PLUMB Nit
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LICENSED CONTRACTOR'S DBCLARA'I'ION - .Job Description . -
1 hereby atrntn Ilam I lin,licensed under provisions Of Chapter 9(commencing .,
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Code�rs.dm. Ylocro,w,M1Sf ]'C! c�` 3
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Data -
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3 u]n" �� ( ARCHITECT'SS Dan L '1l
1 midersmad a,y plan,shill bo used as public recants
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Licensed aide,.dnml
AD A/C '
OWNERBUILDER DECLARATION
I hereby:(prat that],,,,a
c.coma'faradic the Cennn,Co License Law for the _ -
Zya which re reason: eOdic("Zptruct,,anoss and Profession,Code:Any city orcounty - ,-
S❑ which require,a perm.,re ..... a alter,Improve,demolish;fi repair any statement 3 m 'h t t. .. I ray : he pPl t f 1 permit t 1 g t t to Heol •- - :
,hon licensed pt-main to the provisions ofat Contractors iLicense L (Chapter Sq. Ft. Floor Area Valuation
a eeing wdn Scotian cal a the 3 nn a ." ,a P r : x codon $3000
11 that M1a is mama,Erratical and ilia basis tar the alleged exemption.Any d ocofa,
'' or Sectionot more
by vnydreddollarslicant apenoh snbjwtsthe applicant toacivil penalty p��y -
'en,ot more Nanfive l,aneree e,ImnF($spB). � iI`1 ��u� 00 { Occupancy Type .
01,as ownerOf N,propart,or myun'ployo,"with wage,ae Noi:raccon"Onswit,n,
,ill d ,M1c work,and dt ,acro :ninterest r offered fr ale(S 7144,
Business d P r : ,Code.Tba Contractors License Law discs not apply In so _ Required Inspections
weer Of p'npeny Who boulds o'mpmves thereon,and who does sun,week himself -
or through his own employees.provided that such Ioprovemems are not intended or
Offered for side.If,however,the bidding or Ioproccment is sold whhin one Year of - _ •
iimpletion,the owner-builder will linea the bander of proving that h,did not build or -
mproveforpurposecfsele.7. 303r — ROUGH MECHANICRL-
❑1,a,owner ofthe pmparty,v xcmmal
, ely connecting w iN llchnacd tumomr,1. 304 — ROUGH ELECTRICAL '
can....a,the ponce,(Sea.70,14, a.,,,sad Pool ..io,,Cmli The Contmetarx 505 — FINAL ELECTRICAL .
License Law does not apply m an owncref Pmpeny who hutlds Or ar,orsw thereon. -' -
ad who contracts for such projects with a eertmem s)licensed pursuant to the SOA .— FINAL MECHANICAL
Cntractors License Law -
❑1 am enenim under Sec. B&P C for this roam
0,no, i Date
WORKERS COMPENSATION DECLARATION
I
hicalry'affirm under penalty ofpcUrry one al the f ll " 6 dcorrmin
❑ 1 have and 'II maintain a Critical, 1 Consent I elf—"melf-immic f W kc : _
Crin,panclum, i.. arc Jed ple, by Section 3900 of the Labor C le 1 the ^
pcl rthe kr h' h th:p , : I. • . • v�"
Ili Il maintain Worker's C ptc. Insurance, bySection
the Labor Coup,for tire perfuncence of We work for'which dis permit is -
issued My Wn Cannot p>tair Insurance carrier and Policy marber are:
-
CERTIFICATIONOFFXEMI'TIONPROMWORKERS' , r
COMPENSATION INSURANCE
_ (This section need not be completed it the permit is for Ono hundred dollars s
1$100)or07-p"p,
tit
fa Yh -o m fll krt 1 htM1 permit':i.: dl
sh 11 , a an u"r. pl ,be Work'
s' '
Appl Ir
t•, ,wirmp, al
LIe Wal If Cmap ng..p Ce am,a I F,Labor
n yin should ,
be' wit comply
Ilia wok COmpen'I p ns ohne deemed
Cede,d. must
O O _
forthwith comply with such provisions or Nis panne shall he deemed invoked. .� � •
adti ,I CONS I RUCTION LENDING AGENCY
` 1 hareby.militiamen m Igage Y I the pv rbanumen
W
adds,work for wh oll this pornal 1,dsu l(Sao.1197,CI,.C)
(� Lender',Name
z Lender's Addicts -
1 cenify thin 1 have read this application and stoic that the drove inform t ,n
Ger correct.1 to comply with all cit d county ordinances and state laws neletins - -
QtF.) to buildingconsnuctio,and wrchy analmize""O'ntvtivm ofthisci,ymenter, upon
th an
, t J p { ry - 'n p n para a' /
ti y (We) t fy dA ph 'th C'ry ofGpen no against -
Uz Itoi:iw.
a. 11 nilf " A paneh may nary way accrue against.aid
""ANT DER AN p Ag Wit is I COMPLY WITH ALL N N POI T ''JSSned b ��- � Date 0 ^"vu
Sf URCE R I tN. S•— y. ��/
�o 60
Si ma¢eof Applicant/Cmbmcmr - D Ia Re-roofs
- HAZARDOUS MATERIALS DISCLOSURE _ -
Ili the applicant crouton,building occupant store or haone haeardoua material Type'of Roof .
vxdefinedby the Cupertino Manieipal Code,Chapter 9.12,and the Hmlthand Safety
Calc,Section 25532(x)^ -
°Yc, °K All roofs shall•be inspected prior to any roofing material being instilled:
Wit it"aps,lieantmfuture•handling occupant use equipowoto;dwiceawatch If a r o is install without first obtaining an inspection, I agree to remove
emit hazardous air crifi m ucap as define)by the Bay Area Air Quality Management
Own,,' alJanew tori• f r.in ection. Applicant understands and will comply with
yes N° all no p int q r r ulations.
I we norLd main mx,er q k d CI I,o 6.95 l the-
it
Cal'F t Ooh&! ,y C d,Sect 25505 2553)add 5594 1 -n d th . •• T1 )06 'ZZ) A
- if the bu' a docs •tl have mmol,Nal it amy lens'bilty fo notify the _ w n
,t n"marl of here ,oats high lm,he me,prior,o Ixauanee Of v CuniOcom or
Occup'e, r "SignatureofApplicant , - Date
omammeeaep.agent - $ tem• All roof coverings to be Class `B"or better- -
OFFICE.'.