00090155 CITY OF CUPERTINO _
BUILDING DIVISION PERMIT CONTRACTOR'INFORMATION:
BUILDING ADDRESS: - - _ , ' PERMITN0.,
OWNER'S NAr1E: - APPLICATION SUB DATE,JUST, W _R F_ INC5.
SANITARY NO. q 'CONTROL N0.4
C at X ARCHITECI'IENGINHP,Iti - _ BUILDING PP.RMI'r INFO
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CONTRACTOR'S urmar,DECLARATIONChi
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Job Description
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u" 'tion7r afiirm,hallomliconscenials pnsvisiomoflo C,ni L do,mancing
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gill, I 9onmm D' iSonne el lP r.:. c mane uyl
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fiat andC� 6R .
XX O v Dat, e CI ys' >GY1 C racier Aky`'1N ' -
W _—_( —' — ARCHITECT'S DECLAR 1 0 _ •
to "1 understandmy plane,ball be aacd as yublic,,Ce c+,
was WATER HEATER ,.
Iv 00 LicensedP f.: 'I
OWNER-BUILDER DECLARATION
a w o mI h hr aft r O.,I the Character's I Loop, f tl
CXi foil g .(S 20314 B .' dP f Cd Any my
41M which
qu peon Perna u,netnm alcor- pmsu ea not sib tr rcpa'r any.m amre
, 3� prior If, I :the applicantt by 'ra fl 'g J,I totnent ,
matt f dp a deproarsitas ofthc t t L L (Cia,ler9 'Sq. Ft.'Floor
(Con mere tg with See.o t 71HI0)nLDry e n l p of the Basutoland P'de,caro Coact ,
or he is uxempl thehefmm and the basis for Iho alleged exemption Any violation
of$aLon903nie hundred
dollar,
oll Cor apem,it aubjecn the apPlicunn n,ucivil Penalty ,
nrnnlmnhemanavabnndheadauars(55pe). �APNNumtier. ' Occupancy-Type
,Ola 1 pulp11 cour harecolnue, .. .
will do the walk,and,the-stractile is noCandarded or offered for 'I (Sec,9044, -
Business and Professions.code.The Contractor's License Law w'ate:not pply In an RequiredInspections `
w fp e l
py Whohold p nl d whoi h kn II'
orlb f gh h'. nply p ddtht. h p I t'intended r �7G{� Oj.S. ��(
off ded r sole.B,however,the building or'mp'wm
cenl' st Id within one ywoof , .;
eourect rn,trio owner-bmleer will hboa the burden nrpn,vine that he did amb,nld or
improve for purpose of ne). •' - -
01 nl I - string m 50C - FINAL PLUMBING ENERGY '
Lansdnct me project(see nwa,BLs ne s Card P re:C ,.Cade)The Contractor's - 506, GAS TEST '
icense Law does not apply to an Caller of property who thrills or Improvae tbacon,
Cad wbo contracts for such p jects with a Conclusions)fieebsae pasaaat to the 507 -' FINAL -PLUMB-I NG
Contractors License Law. " -
' ❑Iran exempt under Sec .B&P C lonhis reason
Owl + Data _
WORKER'S COMPENSATION DECLARATION , s
Ihereby effimt under parity of pejur,one Little following declarllimtr'. _ .Q
❑ 1 Ease and will'ntaintain a Certificate of Consent to self-insure for Workers • -
Cmmpensabon, asprovided for by Section 3700 of the Laboi Code, for the
performance ofthe work fonwhich this permit is issued-
❑I have and will inuntain Worker's Compensation Inwrance,as required by Section
3000 of Iho Labor Code,far the Iwrfonnence of the work for which this pennil is
Issued.My Worker's Compensation Insurance carrier and Policy number are: -
Carec, r VA-hvl Policy No, n?',K% OR
CERI'I FICA'rE0N OF EXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE _ ..
(This section need nal he dand,aca d the pennil is for one hundred dollare r
($100)or less.)
1 carry that rn the performance or the work for'S Wall this permit is issued,1
shall not employ any person in any runner so ns it)bmonm subject to the Workers .
Compensation teas of California.Dune + f
Applicant
NOTICE TO APPLICANT If, ft C , his Carlificat,of"Capron,you should + _
� bac Ij n th W k .0 p 't I flh I'h CJ y noel `
ferlwth comply with Iliov sats ooh pertit shall be dee ala _
F.� CONSTRUCTION LENDINGACIENCY
1 hereby carrot
that them Construction lending agency for the perfom ante
Athe work lot wh ch this peorldfL: s,aa1(S .3097,Cc,
E Lender's Name
Z Lc d :Add....
V Ifythat lh dthis lip,fi,on' all ,., that b hise infornal in is - -
:T+ [r
corem I L,acI,enanny with all any old e at,ordirsoca,and ,Lee how, nutting • - - -
0 V mbuilding nwgin ,all hehehy authorze rephesenmdves t tho,cityI enter upon .q u
he lmnve-m,atlaned property for rnspactim pgp... u ( .w -
F-4, (Way ri to save,indenmify.,to keep harmless the City of Cupertino againen
I'mb II palgracons,Cost,and aspdroa, h may is any ay accrue against said , -
V Z City in Consequenceofth grandingofth perionit. -
ADPL NT UNDERSTANDS ILL CO LY WITH ALL NON-POINT Issued by: Date
o,
If
C REGULATIONS Z� y
raCIA ppLaantlCCntmet., •' Dale. ,Re-roofs - •. - .
aHAZARDOUS MATERIALS DISCLOSURE - -
ti '
Will the opplicanton future buildingoccupnistre Illetr a I om'rrial' Type Of Roof -as defined by theCupari m Mu i c'pal Code,Chapmr 9 12,and the Ile doh and Safety _ s
Code,Section 25532(a)^
1:1 yr, Ed No All roofs shall b6,inspected,prior to any roofing material being installed. i
Wil the apprlcant nr ratnm handing ocenponl'a=a�gnipineaor eeem�wren =''If a roof is installed without first obtaining an inspection„ I agree to remove
mit h;aunlrnn air"oolemma.,at defined by the Bay Area Ac Qualhy Monogeniam x
rnnmt4 all new materials for inspection. Applicant understands'and wilt comply,with
'OFF ❑ve ON.
allnon-point"source regulations.
I ha,ti head the thrasurnoori no,tilromesns ander Chl Ii 95 of Ih _
Calini licalth&bftyCd Sections 2150525533 and 255341 understandthat -
Ifth h 'Id heti e.nl a enllyl "I Ilhtt }
poinsibifityt notify the
oar run ixqu I' li ch mof
0111 'gnature of Applicant• ,Date
All roof coverings in s to be Class "W'or better
aolhnri neat Done = g ,
UFFICF