00120152 CITY OF CUPERTINQ -
BUILDING DIVISION . ' . PERMIT CONTRACTOR INFORMATION:- -
BUILDINU �SS� �
Y'R Ii NO.
OWNER'S NAME: - APPLICATION SUB DATE, `
t PHONE: r ' •_, SANITARY NO. - CONTROhNO. - '
0 z ARCL{ITECI'tiNGIN13BR: BUILDING PERMIT INFO
N6QC,,%NELECT PLUMB MECD
_NFQD
L CI
O H Z LILFNSPD CAC rOR S DECLARATION -
Z_o I hereby ni'I that 1 1 live ln, f t l'utnehlg Job Descripti
FvJ m wMSwt 91Ieorf3IIhe the II 1 i,C.. Ilny l' af.vc
is I.hall fell.a - -
�� � a.
L nse CI :. I p
13 LL Dem Oormctor
C eve p ARC HO[C DECLARATION r
:E�y� I undemend my'plans,chat[be uvJ n,public reroNs
u6�7s p 0 Licensed Pane,,i
�x OWNER-BUILDER DECLARATION
1 herchy union,ha[I am exempt faun,he Contractor's License Low tin,he -
�?,O ,fo�lh g (S , 70315 B .- a all f.:- n Cd Ay ,y nwuy
yy ,orea aP nt)conslort,alter, tp M1.(it rectirany so3thrc
6, m
prior In II y ire the 011 III I permit If 'y I:Innn6o _
that he ledf t In the plaoilion,oftl L f f r License Law ch,lrer9
-(c m see ty w'tFloor Serbian 7aq Ullman 3 d 111,Bu,in and n fc,s nCode) q' Ft
Valuation
or that he rs exempt divisional and the luau,for the alleged exemption.Any violation
ofSection 703 L5 by any applicant for a Iscoub subject.v the applicant it)a civil penalty
if nor own, hun
has five dred dollaras5ta). APN Number Occupancy Type
❑I
as w at the property. r my mr,loylines with ge- ,h a mpc nation.
will d [tic work. d the sloacturc-11 n [intended arroffiand for.ul (5 7134
Business and P 12:3 I. Code:The Clinometer',l i L d ,apply to as - Required Inspections
ownero„nspurt,Who hail,[,arinpmves dere t,.md who dela„ch w,rkhnesell” -
or through Ill,own eon Ia ccs. +
g p Y pm.War thin such I upfmvcmcnb arc'nil intended or n
compile fnr sale.II;howcvee the building a mown al m,r sold within ane year of '
completion,har the owner-hail.`,will have,he material proving lkn he didart hail,[or
improve lin,utpnu of via). - '
❑L as owner of the property.am exclneively contracting wilt)licensed comrecmrs to
cloolowI v ia 1 I(Sec.h Pro tl sin.l and 1 f,.Sion Cal )Thcontractor'she /✓ _ .,
Li1 1 aapply t ownerfp pent who bald improves lhemm.
and n variance;I 'u h prod c w fl m elan(,)licensed p :u'of , ,hc + -
Contractor's l' 14w
EI Inan v,oma,luaub,See B&[I Cfirz Ibis" r
Owner Lane _ .t
WORKER'S COMPENSATION DECLARAI[ON
I hereby affirm under penalty of perjury one of the following declensions:
❑ 1 have and will maintain a Certificate if Consent to self-inm a for Worker's
Compensation, as provided for by Sealer 3700 of the Labor Cade, lin ,he
tJ performance of the wink Por which this permit i.issued. O/.
DI have and will arnialon N k C ,.real' 1installedbyS tion
37W f theLabor C 1 I ,h pert II f J k f 1 I 1 n,is
Iss J 1yW sC tc 'fof n, I 1 JRI'ymnfhe
Ca ''r. Pml'cY N ��
CLR" AI ION OF EXLMII ION FROM WORKERS' -COMPENSATION INSURANCE
Chis section need rot be completed if the permit is for one hundred dollms -
ISIB1Borlots.)
1 certify that in the sorkarmarce of ilia work for which[his scroll IS issued 1 ,
,shall not employ any perms in any manner so ax to become subject to,he Worland
Compct,sadon Laws of calif ormio.Data
NOTICE 10 APPLICAN'B lL after making do,Centilicme if Exemption,you Should
zberonresutpo to flue Worker's Cmifensuunn pnovi5on,of me Labra Cale,youlnon
QZ
O fonooifh comply with such provisions or[hi.permit shall be deemed revoked,
F
CONSTRUCTION LENDING len AGENCY - ••
ai 1 beteor wRmt,ha,,here is a ammmmion lending agency for the performance
W of,he work for which this Penni[is
Lender's Name issued(See.3097,Civ.C.) ,
z Lender'n Addm,
V fesf�•,. 1 candydrat il Ito „li I' I I:,I-thatt b I' I' • '
verret:l er g I 11y M t'anal n d f f (
I ly
t.7 lobuilding eaulmcl, ,and rebs mh,rr e'ne'll rive fM se'ryln wrr open
ry the above-n an[ioned propc fnr in vii pugmsnv s
' ly
(We) go.m save ndemni 'an ce,hmm ss the Cifvif Cu,ertino ugain.a
W Coy idemeopmenl,,f c and e n s which o is any way accrue againu sail
t„) z City in cinroyu cif a gmn,i g if Il.v ttish
APPLICA ER 'LAND NDt L MPLY WITH ALL NON-POINT
R "1' NS. _ -I� J� 00 Issued by: _ ,Dat
Sig mr, pl lean ,a,m or ]),lie Re-roofs ..
IIALARDOUSMA'I'LRIA.S DISCLOSURE '
•Wiumelpplie„pnrmwrebuilmon,iceu,nnto...c” handlehaeanlamdaaaiul Type of Roof
as
efinW by the Cuper[inn Munlcipnl Code.Chapter 9.02,and the Hmllh unJ Saftty'! '
Cale,Section 25532(x)7
❑Yes 0N
All roofs shall be inspected prior to any rooting material being installed.'
will me."listmnr failure naudirg oucupam use eyuipmem err deice,olden If a roof is installed without first obtainin ;m ins ectiori, I agree to remove
emi,hawNous air elimination,as defined by the l{ay Area Air Quality hfonagonent g P 'g
District" all new materials for inspection. Applicant understands and will comply with
nYea ONc all non-point source regulations. -
�� I have read the bettor us anci 1. un "mule,Cha,lc-695,lf mr�
Cul'f H I Sale, aetialls 2550 551 and 25534 1 understand that - -
IfMClwtlofif , u, a,I ,of,ady veatt be, l it ay mvponsiof. ,nfifl,n the '
OccuPan,of tl•re, in t ole wh-'M1/pusl M:t el grin ,o i5.wance of x Certifiome of
ccup lv// , -
12/17-00 • Signature of Applicant Date '
o nte,maamairwa - Dam All roof coverings to be Class "B"or better
OFFICE