00100093CITY. OF CUPERTINO^
CONTRACTOR INFORMATION:
BUILDING DIVISIONRER VIIT,
BUILDING ADDRESS a : If-'
-
ATLAS HERTING
PERMIT NO
fcti01,fd01t193'
923 BROOKGROVF_ LA
.OWN I ER'S NAME ''
- -
'1,55 AVEItb%12/E0Q10
APPLICATION "'K1
.,
KHITRJU
.SARI .LAZARO
HOST
-
SANITARY NO. CONTROLNO,
".
6,408)739-051,6
O z Z
ARCHITECTIENGINF.Ek:r - -
, ,' -
- • HUH.IIIN . PERMIT INFO '•
e
BLDG ElECTPLUMB MUCH
�`-,
r zIJ
..
..
-
rr¢d
SI- o NDECLARATION
_ .,.:.
LICENSED CONTRACTOR'S DECO ARATION' •'' ..
�.
- •' Job Description „
:
1 1 h -enY M n Ih I I rued e I ''. sal Chnpier 9 tRonm Rneing
-
y, �ce
, hit Section 700(4 fluym 3 fineBu dProfessionsCode and ny license
u fid Clahs dad, -jL
REPLACE ROOFTOP , PACKAGE' UNIT
a
-
- :AHCIedECT'S DECLARATION
understand my plms-.hal,
1 un"ersbe used as public records'
4f
pz
Licensor] P trial-
OWNER BUILDER It UNCI ARATION
11 by n that pt f II Contract L In
...
F z a
3
toll g (Such 9031.5 H I P I Code A y city re
( t
-
�0
t c
' f
"
e.
pri t t A I 'th pplln tf I p 't 11 g J'I I I
- (
S Ft FloorArea
q'
_ Valuation -
mntl licensed II h P - to C I I L L (Chapter9
-B
Icn g tb Scene. Talo) f D' 3 f d d Profession, Code)
-.
- $ 0
�@
nr mal he is exempt I....in ,,, ane tee hada or the alleged exempfra. Any aoladerr
- - -
-.
of
nal Imre the I fi,n l by y eapplicant in, Sson). n;�x Inc applicant ton eroR penalty
I, r"
.. APN'Number'
Occupancy Type
❑I as ownerof[IlePr p tv r employees with wages as thernsrle armwiisainan,
37539026. 00
will do the work, and the str uurn t intended or offered for .a]e (Seo 7044,
-
BiaI P f Code Tk C a: I ' 1- e I apply at
Required Inspections
-
rfp p iy Whon la p I dn 1 t kr ell
-
303 — ROUGH MECHANIC
ALotl '
-
ghis employers. p'Lied that h arproventals am notit d d or
offered fa saleIf, RRICVIL, the n lid t'. Id. tlu R e d
l
- '
304 — ROUGH ELECTRICAL;
omplfa, Weowurhmhkrwmbase burden of raising that hedd,nlbuild o;
improve
for pnrpnsR
505 . --" FINAL. ELECTRICAL-...'- . -
•,906
proper y.am
❑hax nwae^'f(he ' y°a' ,wi m
thodeasTie
r'r' — FINAL- IYIECHANICAI_
Bookie, P...aw coder Tee Contractor
Contract
,aromel the pmlecl (sea. 9044: owner a ane Pfy
Llecnsc
, r
Law nor mon owner of wen milds
will impeavcs mown,
. - .• "
It navy
o I fort 'e
rn 'n p',]eaI win, a =o llrt err a.) I naat to We
rich
Contractor,real
Cat , t . Increase Lux J.
❑lam etempl unecr Sec.' , B k P C far Ibin reason
'
Owner Irate
r e .
WORKERS COMPENSATION DECI.AR A'f10N
r 11
O
wyreny arum order veaahy or Bitry ane nr the ran i ` g a a
areas. .. .- ..
/ice
❑ 1 hove and will notean a Ceaificmc of Consent Io self -insure far Worker's
rr .
Compensation, 'Its provided, for he Section 3900 of the Labor Code, Innth=
isefform ance aidework for hi hth: permit is isimed.!
' r
711 bro, l d will R.arpamW k Clunistailisholl JIrducedby5 f n
•-
t a
3900 of the 'L.R.a Pod f thepar , f the work f which hit, 'pr.r r I is
l
i. NIy ader sCompensation Insurance-
��d�Pol'ynumb
313
O Q
7
Currer Policy No.. W( �
. CIBOU CA N0I EXEMPTION FROMM SLRUID
COMPENSATION INSURANCE C
_ r
(Thus section aeul on, be cantpleted if nre permit is for one hundred Anllare-
'
(SIIIO)or 1eue7
I L and y Ihot in the perfommnc, of the work far which has proof is ihsted, I
shall nal circle, any person in any manner so as to bcconm sullen,, the Workers'
-
•
Conowi,tion' Laws of California. Dare
Applicant
.4 .
NOT ICF fO APPLICANT If, aft eking II'. Cerofflcatctrt Exemption,you should
%a
hoc mto l toffieWoron s Compensation I (if the Labor Coca yon mm(
Q
foal lh comply will R,RwoiiI pant -shut becle6road e ked
4CONSTRUCTION
LENDING AGENCY
Iby rml [her, k R comontratten leading ,.a, fr the padwounce-
for
✓
W
of the work which l0 prat: sacd(See .3097, Ci,: C) .-
- -
Q
Lcndcr'sNamc-
z
• Lead Add ..
t.i
I Ifr II tIn s ad this apll' I:tt tl t the rhova;iiformula , •
•' Y .
tort L 1' t ply 11 e c IY b' t d ml I Int n6
nth Idg=mslnefo,nepy
_
' _
J
[�
iy W
a e m
I... y.umr ntsoR nm tea IW sa'ly oenlRrupon
my,cat p p. ,
the b f e p i ode
-
Fy G.
if
(W) g lave indemnify pial Ic'the City
rarme
° ..
r� h
Ci Z
anoag'.d
liab 1 t) db ts, c t e p acs which m y n any y 3ccr e gAn.vt said
ay
city race of g r n g dlhisp,rnt - -
•' - • .Is
APP CAN NDE DSAN¢))rIL�L.�%ON�TYWITH A NON.POI�T
so ATI D�j/l��-,VO
Y
��11
Issued by:-.`` - Date 0V
grwm rr , pprc,at)Ca as ter ' Date „
Re -roofs
HAZARDOUS MATERIALS DISCLOSURE -
.. 5/
�` Will Incapplicantur lame building occupant smrco, handle haindaus material
Type of Ro - •, `
us defined by the CupertinoM mal Code, Chapter 9. 12'Rrid r Hath and Safety.
r
Code, Section 25532(a)'. -
n '1
❑r=. oN
All roof shall be inspected prior to any':roofing material being installed.
- Wu meavpi cot farm, b 'ld g 1, t yap 1 r wbm6
retention,
If a roof'is installed without first obtaining an.insP, ecGon, I agree to remove"
eruilair comonnunnif, defined by the Bay Area Air QualAMamagement
Diart=t" ' t• ..
11 Y"
_
.all new materials for inspection. Applicant understands and will comply with
p. PP P
❑Nn
-
-Y
all non -point source regulations..
read the hbuardkia, materials reyuiremems under Chapter 6.95 ofiea
_Plinve
Cali' iu HcaWl s@Srvl'dyCode, Sections 255!15, 25533rmd 25594, 1nndr.urndthal
L chuilding"'a' not currently have mnnnl, that it is my responsibility to notify the
of ie requirements which must be met prior m iasuanca of a Cenifiune of
: ea ' ev - a
, - Signature of Applicant •• Date
All roof coverings to be Class B" or better-"
Owner t ra s rat -Date