01040128 ;.-NEME:
ITY OF CUPERTINOBUILDING DIVISION PERMIT CONTRACTOR INFORMATION:,
ILDING ADDRESS: PERMIT NO10388 'BYRNE AVE 0104 1-'R'SNAr - APPLICATION SUB DATE
WTLLIAM CHOE 04/c41aooj
ONE: _ • W SANITARY NO. CONTROL NO.
tto' Ji F
.p W Z ARCHITECT/ENGINEER'. - '- . BUILDING PERMIT INFO '
�. iu m LECT' „ PLUMB `{MECH
CyyF -
LICENSED CONTRACTOR'S DECLARA910N ., Job Description,. - s
0 Z C 1 hereby alFrtn that I a licensed no p f Chapter-9(commencing
G with Seuou90B0)olD n3nf NeBu snnJ Profess' Coc,anA nyJe se, - - , ) ,•
y "a ix nThe full face•nt'dife / /` - 1..
t(z Lccn:ec' /foo.51 'L�n « - fOIurandarO ;, TEMpORARY'-.POWER
' �0 _ -I .I o y plans shall beusd' puhl'anever
W O O LicensedProfessional
OWNERBUILDERDECLARATION '
. ad I n c ebr arF m th t l ,f d C I L ' 1 for the _ -
�S�C tollovis
g a n (Serino 7031.5.Beside,a I Ponfit,mun,Cd An,, ly nap
fFD w'hirm feature,it-praniat I II p I'h p. ystueure.
413m pr rude . . .I' 4.i 'In rN It h , file 'b Lrl 1
that he Ificenaled,sarearmudiflGe, o fd C 'I L f' (Clap) 9 ( S Pt. Floor Area Valuation
I(conmeae agwIh Secton 90018 of Div3 fN BuBullto dP t ConeCoon) r' y', a
n Onto,I ,a tberefro n and Ihe br f theIlegml pi Any virl of on ( -(
of S a 9011 5 by any appl'cam fore ornotsubjects @e apigicienimanivil penally - '
(if not ore man rive hundred dollars 5500) - - .r �,•.;APN,Number . _ - .Occupancy Type
❑1,vs uwm:naf the Pmpeny.ar my elnployecs with wager as Ndnule compcnwlloe, - A n
woll do he work, ad the optician, ,intended or officard'horIn(Sea IDY,
-
Bu .,n d Prefe,im,Care The c l t ,Licerpo Law does but appy to an Reyuireddnspec[ions
thref property Whobuilds o improvesd eo and el des such work himself
rough hfs awn cmplerccs.provided that such improvements are am amended an 103 — LIFER .
offered for sale.If.M1awever,the building or improvement is Told within ane rear mr - -
• inapmean.the awn,troilda,will have lot hamenpf,rurc.gthat hemdact hand or '3'((14 -,ROUGH ELECTRICAL-, .
mprove for purpose ofeale.). -
- '- /
❑Ismawner reject eeay' I ly t Ftg lhleensThe radiation,to - '
ari,the prated(Sec."1044 non a ander(, pore Coder The Cmmmem'T
and who
Law does nm apply man owner th properly What bufidv or ilnpnwes i a go r.. - s _
` and was r,Li cls for each projects with v ammdm(x),licensed purenlam In Ihe
Contractor,mender t
❑I I pt andcrs B&Per m'. -
Owner Date
WORKLRSCOMPLNSAFIONDE(LARATION
Ihereby Enin ordWischIft,fortgothay no of 11il following d1chapefl
L 1 Fare and will madinarin a Ceptaficale of C sent to wli-amatc Par Workers
Cop t n .0 Prov Jed for b) Scion 3900 of,lh Cif Code, for the
. . performance of Ihe work for which Ihis permit Is issuul. , - r s
t
❑l have and will maina'I Worker s Conipeischitin insurance, rere`dhrSection
39,00 of the Labor Code,for the performance [lie e work f ah this permit's
slued.My WndsrN Compensation insurance carrier and Policy number are ' -
.,
Carrier: •+ Policy -
CERTIFICATION OF EXEMPTION FROM WORKERS'
• COMPENSATION INSURANCE.
IS14(This f e not1 conflicted if the permit is fhundred Jll '
le"'.)
certify mat in ine permumand,of the work for whiah this permit, d i
nhall n couple,v it,person in any s m bee me object to the We ke Y
Compensation Laws of California.Data ,
Applicant .
NOTICE TO APPLICANT-If Iler matureN Certificate of Exempt ma you-should �.
'QQhemme sl b,e,f m the Workers;Ciam,erparfour provisions at the Labor Curb you trust
Tani,ith complywlh suchpoviions orN perrit shall be decnmd revoked'
CONS,,is a ION LEN III NG AGENCY - -
IhrkforwfrnNul .ween leadingagenry fair per4innea
.rte .fir Lea work for M1 ❑ coupon's issued(Sec 3119'1 Clv.G - _ -
sr z
Leader Name
IG•'/ Len I Address Id esx
0 Ices fr that I been oradlh 'i,dwaidnand stile lhit, h h of reniume, Aa• - - . .
W
F'
Q�.t'yUW
-t,roil.1 gene to comply with all r and county
DoaunPtordinances naves-one'nae laws regain,
lJconstruction,sand briery representatives fah:Gy-ad emerabout Inc abovWoend and prm int,hoi ,endsnn
(W) gne,to I fy • ✓' - _ - - .-
-
- .
f keep h 1. NcCity I Cup tagu n
V) liabilities,judgments, e: d pe s wood,non,' lyy income ny, not W
V Cityi np.rmh
CANT UNDERSTANDS ANDWILL COMPLY WITH NON-POINT
URC '
ISSnedby' v
DateREGULATIONS
-
I '
Signature of Appl'IanUConwctar - Dam . Re-roofs
HA2ARDOUS MATERIALS DISCLOSURE
Will the applicant or future buildingueeupentxIran a,Imadlchvmmetnsmmedal <Typeo'fRoof-
as defined by Ihe Cupertino Municipal Code,Chapter 9.12,and the Health end Safety
.Code,Section 25532(x)'• •sir . . „,�; ,
.°Yes'-. - ❑No •. All roofs shall be inspected prior to any roofing-material being installed.
Will the apphcnm onfluane bolding occupant moegmpmama.devirs,which "If a roof is installed without first obtaining an inspection, I agree to remove
edit hezarde,air cohiminum,us defined by The Bay Arca Air Quality Management - ”
grid:' all new materials4or inspection. Applicant understands and will.comply with
❑rax ❑No, . all non-point source regulations. -
+ 1 have read the h darporx materials h,mocmems node,Chapter 6.95 of the - -
CalifominHealth&Sal'dy Coec,Scmions25505,25533 vnd2553q.I undcrmmadlhm - ( -
ifihebmikdo,doe,notcurremly hovev mnan6lhnt it is tniy resporoibility In nmify the - - a
ecp t fthe mnuire t"lichin Ih Ip In�eevvneeafa Cerlic ie of " -
°ro ' ' Signature of Applicant„ Date a.
. . t,
owumaramnmrnee agent nate - All roof coverings tube Class ".B"or better
OFFICE'
. eo. f