01010120 CITY OF CUPERTINO- -
BUILDING mvtsiON 'PERMIT CONTRACTOR INFORMATION:
PERMIT.NO,
Bua.l.!. k'i1�.viR Ct U,IY 1JR -
13193TWATER T'IERTE,16,.11%1[: 01.01.01.20. '
APPLICATION SUB DATE
I1ad(i1a._YN M 1'hlJSTE E 1764 E,k 1411101,Irt. AW 01✓;0A.?lilt%1.
�•.PHONE: SANITARY NO ,.CONTROL NO.
9901
aANECIt „ -{BUILDING PERMIT INFO
RCHITECTIbNGI
❑ BLDG'•' P.LECT PLUMB MECH
g iad
Z F - 1 ICFNSED CONTRACTORS DLCI ARAI ION Job Description "
O Z Q I hereby f i II h
wens ( 7wd) rD' " nn3mnne Btt .,ndl-r.., .c e,.,doe ny gcenen
t "infullarceardObect.
L p• `< a rT ? h. S - : ET
-License Clans
LDom Contractor
de aa , ARCHITECTS
n
-
DFCI ARATION
I ande,hardmY pP ,fiall be used'. P bl' d Licensed It fasounial
s,
WW N'
n.a
Oat I m BUIL DER DLCLARAI ION
calla, I hereby Iran on 1 1. we sine fn ,Ib Contractor's License yc Law faiths, s
�y following rensvn.(Section 7ounit ,alter, ora Pn;re,.ions Cude:Any city or wanly - -
P t�G wh o ts . P I I < I h P e J 1.1 p y sarturture,
prearth itsLacquiresr applicant f 'shPeriod n filed ,I
mp
dtl licensed l I, n provisions
rho c I , L Law
(Chapter v Sq. Ft Floor Area . Valuation
I"mirroring ib Section 70011 fD B.1 he Business11 f.: Cd)
or mar is s exempt therefrom and the basis farthealleged toemph an.Any violation _
of section 7031.5 by any applicant for a permit subjects the applicant to it civil penalty
of am more(him r re ha itioddollars($500).- APN N umber . Occupancy Type,
12 I,as owneror Die ad the sonny mis of intended
nwithwaperfe theirsolan (See,inion,
sr:�laeu+ta nn-�
will nr the work. ad the ode The is not int rry Li ens Law for sola(Sec 7044, - ,
owners and eryWhonb chole:TheCom short uadw o d Boer not apply m an ` ' I , .Required Inspections -
rorprapenyWhan,yiec,rimproves aledtahuum,aodwhaJaest,, atorkhitedor O. ... . 1-.—)I. F;'CAJI'UF3xl+lfa fii7�IF.:Tif.'Y
or through his not however.
t building
that-such impnwdncros aro not I,at yen,
�coofferedmpletion,
In.nawevao ore na'tase t e inrmorprio n,t h1 whom ane year ar =i(%)C. — GAS TT•.CEi7 - ..
' ompletioa,the owner-huilAer will hove the hurtles of proving Than herbal nm mild or -`
improve for purpose ofsale) : )']. . 1='7:b1a11_ F4_(A•R:txblf3
❑1 f the property.am excciantracring with licensed , tors to -
. t
con,norn to ...... S -]044 Business 1 I ' a )TI C h m
an
and h tic , f such projects with u ennmrt :ed purtam It tire
e
Coo w, rLicense wLc L -notapply fp 1 y h hands 'n1 .mret,
❑Imesn,punder Sri.
-
,P&PCfor ibis ravmn
Owner Dare -
'" - WORKER'S COMPENSATION DLCLARA310N
I hereby argon under Penally of Perjury unit of(an following declarations: - -
.l 1 have and will maintain in Certlficate of Consent in self-insure or Worker',
-Compensation, as provided for by Section 3700 of the Labor Crvle, for the -
,oformsnm of the work far which this permit k issned. r
❑1 have and will maintain Wilton s Coimpunenlion goaranee,as required by Section
3700 of the Labor Code,far the pert rnanca of the work for which Ihl.r permit is
lined.My Workers Compensation Insvrmce carrier and Policy number are:
Gariec - Policy No.:
CERTIPICA'1'[ON OF EXEMPTION FROM WORKERS' -• - -
COMPENSNHONINSURANCE
(This section need not heco ndeled it permit is for one bunJred dollars - -
($100)or less.l
1 certify(bar io,he ,I mine of the work for which lid,penmil In i....d,I -
she1l hat employ any person In any manner so us to fireman.subleet to the Workers' - -
CompcnsmianLawsof California.Dale `
Applicant r .. ,
NOTICE TOAPPIICANT.II'Ifinnorkid,lh:C Ir I f E,dooplior,you:boald _
heroine:object ithe Worker,Ciarminsurionp......orooria,LanturCude,y oust
forthwith comply with suchprovisions orth' permit shell he derhoolfravoked. -
z
F y
CONS]RUCTIONLCNDING AGENCY ,
a
I Inerrhytiffirm thatd n e dingagency f (he perfnm,ancc
(sl of Leah - k far which th 1 is rsuJ(Se- 3097,C'v C
Le
1s Q nders Name
� z Lcnderb Address
L V .. . .
1 certify i..I hm,.read ails city
and,ion and scan.sh.a s and toad information is
coned.1 agree a,comply with all city and county ordinances and$cite laws caller
upon n
r) -,hebuilding
ove-monebaction,and r,bars authorize mprcacmntivaxofthis ciry)ocuterupon
Gil ,he nhovcnegree I l propend rarinp odd keep
.....harmless
• - ° - .
- EyZ es, agreed savesnd,,I aspane keepharmlessthe City aof Cupertinost sit ,
O� City in cousecFennls,costa and ing of this
which limy in any way accrue against.raid
U
City In CAN7,U D of the NDS A D this permit,
SOURCE REGULATIONS.DS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
� -SOURCG REGULATIONS. � Y•
. Sigmalareor AppllciorfConhmmor Date, Re-roofs ,
HAZARDOUS MA'I'ERIALSDISCLOSURE - -
WJln;em,ph,baler roma huildnpi,ccapma$tomm unlle haemdoasmammd Type of Roof
as dagnmf by WaCepenino Municipal Cody Chaner9.12,and be Hrullh and Safely -
- Code,Section 25532(a)'r '-
- .[�r°" El"a All roofs shall be inspected prior to.any roofing'material being installed. '.
Will heappdc,mormmmbaudlag,,,.,iIuse ayaipmcatordo,ier.wld,h If a roof is installed without first obtaining an inspection, I agree in remove
emit friction—air cohouninam,as aeGnul by the Bay Arca,Air Quality Management
Dion"9 .� all new materials for inspection. Applicant understands and will comply with
tj 'ovdr DNo all non-point source regulations..
Ih ddm ld:rd : mt ' ls g errand Co pt Y95 of the _
ali _
iitote Healthy Safety 2m.br I and ,mo, a,inn td lhal '• -
ifthehmoingdnasnohcunenllyhnveost on
thin Il an It,i,, ponsibil by toothif,the
- cupam of the reyuiremcnw which nun be tact Prior m isreancc of a Cenifievm of
tit
Omapaney. " - - - -
- .,'Signature of Applicant Date -
Ownerornmhoriaedagen, , Dade - 'A'll'roof coverings to be Class "B" or better '
:y OFFICE