01050017 CITY OF CUPERTINO '
BUILDING DIVISION PERMIT CONTRACTOR INEORMQTION:
uuILDINGnrn MAYWOOD DEVELOPMENT` -T-1'P9' 01050017
�`o�D53 BRET AVE.
OWNERN NAiNKEITITI 'SLIN .. . ..,^-_057,:r :RODRIGI IES AVE APPLICATION@I 1VAWI/2:001
PHONE: FC SANITARY NO. CONTROL NO, '
(408) 725=:7918 •-
ZOO ARCHITECT/P,NGINF,F.Ri - BUILDING PERMIT,INFO
ly .BLDG ELECT PLUMB MECH'
y 7 LICENSED CONTRACTOR'S DECLARATION
z
5 Job.Descr tion
pz�® in nv rc, that licensed d p .-ren Pt 9c dm tine, _ P -
,p� wm5 i ]Ilam,rD 3trmgB eP r c le,a drny runne. -TEMP POWER.
v a� LicenserCfl .s and of Z 1 +#
w3uy DataC d- d
AI2CHI'1'F:C'I"SE-51-111JN
d t J ry PI II be uv I D�u �jyrR coIONs -
u�1Sp0
°i 49N4KBUILPER DECLARATION '
havedy afec that 3 shpt f theContractor's e Law county
r•'
F'Z a foil g d.feel ]onstru Basin—a A Pmfdam ns Code:Any c n whin ty "
Sr,5 p whim 4 permit I construct,. fica t for such
demol h P y eduane
c ':hill
pr l d '. requires1M1 Ipl tl hp II rIsignal.nle Heol'
•IM1 IM1 .f dp II theP n met the C I I L 1 (Claphcr9 Sq. FC Floor Area Valuationso '
Ic encinswth Section 9onnn,f D'vi n3ormeBnvm IPofessions Code) + •.
I or that he is excupt ancrafroad and the Russ fer the alleged exaniptiont.Any vi I_rind - • -
.afSaa,i.a 7031.5 by any it,haamfor a permasubject,thc ppl 'all ucull normally `
afnan anneflDis Bve hardball l Imrs(s500) - AIN-A b r0• - Occupancy Type
❑ t[
I,avowneraliepropeny,ormyempmw
reaswiwa,c,aaeirn.
ntnnleCompentirn. . ...0. 00 ,
Mil do the k d non stradmi,is her 'intended or offeredf .al (Sec.7044
Bt d Flat : :Calf, Thec t' d :LI La d d apply t quired•lnspections "
w II IyWh h IL p :th d 1 d h won,It
:If ° - 103 '� OF W"
or untrigh ll':own emplayess.provided th t such itaphoiocularls"ard notit I d - .
offered Par sale.If,fiever,the hd'ldep apmve icm sold within one year or '304' — ROi.IGH--El_ECTR I CAL. .
hmpledmr,the owner-bnilder wIlntyva the burden of moving tun he did not build or
inpmve fn.pulPore of n'olej. - ,
❑I r, f thproject
pI( e tl> IY t 11 l 1 auntrad too
au uh p li a e f:.orm Crude:)Th C d s
o La J dapply90uan(owner 44 fp'p ry 1 h W r' p thes,con, '.
and who, ,,a(.,(,fra p-Jetts diddi a cuntruchami)blamed d p and to the .. -
Contractor's License law.
❑1 air, ,scuip,made,See R&F Cr Ih' '
Ow r
Dan
• n
-' WORKERS COMPENSATION DECLARATION
Ihereby uffirin omckhis,'rrall,ef peaturry ans,roftM1 foullwan,ckd I
❑ 1 have and will munwn a Certificate of Conserv to ll m re for Wmkerk "' -• �_'
' Compenuadon, os poet ded In by Seamen 3700 of Thr Lahnr Chile. far the '
perfermence ardor,work for which lhu-s permit is issued '
Cl I bine and will muinWin Wnrkcr's Compens:hion Insurance,as
required by Section i ,e
37110 of dhed.utmr Code,for the performance al Ila,work fur which this pemnit is - e
sued.My Wurker's Cnmpensalien Insurance carrier and Policy number me:
L
Carrier: Policy T - -
CEHcI
RI'IfICAN OF EXEMPTION
TNSURANM WORKERS'
' .COMPENSATION INSURANCE
('Phis section need nat be m..unwol it the permit fs daunt,hundred da1D,r - - f
' . IS I Nd or lr,e)
1 certify Ihm Mtha ptt!innnee of the work Cor wnieh Ilnis pernnl in finned:1
shall nnl adEny any person in any manner on ds la Wermer,subject to the,Wd,whsF '
- l mpe ismw
inn Lax of Culifamia.Dade -
-A,licrut - _ - - •
NOIICLTOAPPLICANI If, ir - 'k g0 C rCl -I f l pY h yon should
becourne,adhicaUddieW kiac,Courpen......Ihankinusal the 1h1.1dra Coati Yen 111had
Q
fuchwitin cannily w'd i p h,ikiddr,rar tl , occal,hall be demuldne,liked.
z .
CONSB RUCTION LENDING AGENCY,
a j Ihemoy oBrn lh Ilh :I' d I dl l6agcnty fur the performance ,
Wfr eewowhich dl parlll's issuer(S a09],C'v.C)
LaN ( -
Lender's Nunn, -
V z
Leader's AJdrass - I • •. , ( '
O
1 ainify fact[Lwith Ili
ppli-i dal n tlh h f n' Nis
W (.y wr d 1'6 t ply land herrn by I ry d dal rer uns
r..I thh'IlnBumsdrett ,,rly handraclua eposes. five (llNelly In enle' Pon ,
W I lhcabn(Wc).tfnncd and,
andikeep1dosrs.
py fwe)agrees save,, and c fry and k which
in m we,of Cdpeni ai st said -
Iloblti ju fgm ode, a d peTilt wt'ch my nary yar ru against said -
,+6,J Cily :9 ceofil gu dnB nrdf.p rel - _ ✓ -
APPLICkNTUnDERSBAN AU,W ,COMPLY WITHALLNO -POINT
So W=11",JrV4TIONs�lr O3 b I Issued by: ' Date ,� i '.•..
sig t pprcan s '� Dade. . Re-roofs '
H Ic
>OUS MATERIALS DISCLOSURE -
Will lheapplirmtocCame bundinguccuper, umeonhandle na,adtlouwmatedm Type of Roof'
as defined by the,Cupenfm Municipal Code,Clnapler9.12,and the Health and Safety - -
Code,Section 255321e? r ---
•❑,Test - N No All roofs shall be inspected prior to any roofing material being installed. _
Will!he at,an prime n ddmg e n .eeaAu e,iee. inch If a roof is,installed without first obtaining an inspection, I agree to remove.
{
emit n d room dye lfinel by then yAreeA Quality Manag eel
°i,t l❑Y es N n all new materials for inspection. Applicant understands and will comply with
I all non point source regulations. _
I hire mad the hozaNous anuteridim
als mymmn,ander Chapter 65 up In -
Cilffanniu Health&Safahy Cade,Sections 25505,25533 and 25534.1 understand that �• -
iflhebuilifin,docnul amaddy haven tenand,thad id is mY respunsihilirym handy the - •.
ircnpanl of the reyuimmenw which must be mel prior sunned nr a CedEra e or Occupancy.
\ A.C''�D�_�, Signature of Applicant, , Date
D.,c , - All roof coverings to be Class "B"or better r ,
,.OFFICE ,,