00060112 CITY-ORCUPERTINO.
BUILDING DIVISION y pER1VIIT - CONTRACTOR INFORMATION:
BUILDING ADDRESS '- ' ' t PERMIT NO.
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OWNER'S
IN
A F' - LICAI' 1
A6604 CARVF_R DRI VF_ CHEVAL .CONSTRIJCTION - N'c &,&dI,'gi].2.
SANITARY - l NO.
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PHONE: StAi -.HWU 996 ,DRRK ST AjIG/ 1 ��
iZ9Z ARCHITECTIENGINhfR. - - ) - BUILDING PERMIT INFO
-Fdz 0 0 1 — _ e" F -(210)521-7421 BLDG F.LF,Cf_ t PLUMB;, 'MECH
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LICENSED CONTRACTORS DECLARATION Job Dcscrl tion
'
=o•y� II byfirm 1111' nl' dmade,p f Chapter 9(Comne cog P "
ziL 70FFcf Demon the
� ylcenseftProfession, d
is fall f and effect
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iiiiiiiiciose
Clnns ni .L p1
up
ON Dat ARCHITECI S DECLARATION t f, '•TEMPORARY" SERVICE 4
I rabacurnalar,pl shall be used as Public records
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wzp0 Iic d Professional.
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OWNER BUILDER DECLARATION
m�o� - Ih bY'ff tuvtl attit Pti tit C I CunrouI Icn Is 't d
t Z a toll g (Section 7031,5,Business d Proteasions Code Any viyorsoundly
2 lach opaipermit to t t lte p t demolish, p'r.ny structurece
ce 3 m "t pit -e 4 R PPI tf hpe 'u fl .'g ed.wtmnam - - - - -
m t l I I p l l n p a a: Rh c a t L' I (chaparral S Ft. Floor Are' a a cation
(Cmani' clmg with Section 9W0)of Division 3 of the Business and Professions Code)
or mal hcis esemp therefrom mad the be...for the allegedeserpaion.Any",lesion
of Sect on 7031.5 by aif, p,l m for a p.at, objects the applicant to a tied po "Ity
ofnetmorethan five hundred dollar,6500):,.p APN Number v �' ',Occupancy$'wpe
171,as owner of the properly,army employees with wages as Far...le ca r,matinin '
tuff J the ' k I ldchaamav I, ac' t d ff I for cilv:(Sr,7044,
Bt a and P re.', c 1 The c t t I 1 d t apply t an - } �g�quired Inspections:•
net rp pe tY wit bald. 'improves m e dh k n :elf .''37,53004. PRd"
nrth yhuemployeesRa ddtht: h p e t t' tad lar 4r'
allecalf I.Ifh 'rtit building p n
c ' Id withinone yvarof - -•'•� vY f `tr
plt t b lder llhavethBmn fpraEiethti d,Inarbnldor X04 — ROUGH..ELECTRICAL '
Improve for Purpose of sale.).. - r ,.,. a
501. — FINAL iELECTRICAL .ENERGY,
❑n fie profane, S IY o t fob litoce)Ihe Centro t -
conwenh project(I ]tori 'B dP f:: Code)Bhe Contractor' — r -
' ppr pmv rw p '505 FI'NRI_: ELECTRICAL '
License Low does nbt a to an ownu of ed ho builds seam r av ion the `r. y. -
` and who contracts,Lice far such projects with v ennhvetor(x) licensed pumuent-tn the _. ' -
Commands
' El it.esead nnderS � ••h . ,p&PCfar aM1ls lessen ' - .. • . )
O's let Date 4 _
WORKER'S COMPENSATION DECLARATION - R
I hereby affirm under penalty of perjury one of rbc lollirvidb declarations
-. '
1
❑ 1 have d ill maintain in C tiGe t f Consent m"eir' : ref W k
Compensation, us provided far by Sec,nn 3900 of.tire Labor Code, for the ds.
- t
v
i f the work for which this 't' '
per lammsao p sued.
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s. .
s ❑1 have and will maintain Worko2s Compensation hv'urnnce,as required by Section ,. .. -,t
3700 of the Labor Cale,for the performance'of the work for,which(his peonfi.,
is
sued.My Worker's Compensation Insurance carrier and Policy ru nber 6r,.net Paley
Nn: 12�Z3t9 -91
ERTIFICATION )FE%FMPTION FROM WORKERS'COMPENSATION INSURANCE, - -
- (Th ': iron need not be contplet d'CO posit isr h died dollprs - „
'f8100)or lc sJ - e• - '"
1 ce tily,haus the perfotnname'ar the work'for which this perm t is issued,1-1 shall not employ any person to any number as to hernow suhjea m the Workers `
+'
Compensation Laws of California.Date .,
Applicant as , �•
NUI ICE TO APPLICANT If, ft b ,this CafF,menfEeran,amen.y I Id s
1-0 zbecome subject to ReWarkers Compensation p :ol'the Lob Od y ma
' fadhwnh comply wtrh such lvpiarsofmk pemt t shall he de neo revoked. - +
CONSTIRUCUONILNDINGACENCY
> -
I he m by ff that there is o construction lending ag y forthe fortavirforipance
Undr,- kf h'ch tit epernn_InauW(Set:4[19],Crv.C)C .Lend r. N to - j - `• -
.`D. z Under's Address
UIthat'[
a1ho read
tlisapplicationvddt Ihttit b f ' 1
s ' _
1
l+ Hcolli agree trsompY wnbalb any d couryorvae and
a a ante a re Ivting'
V rob If g r t dhe city N pre tf e Irht ryl t p .
the r dp ,.I,y for inspectionperp c 1
'y GM (W) g' tindemnifydkph I .tit CtyfClerf g t ,, ` ^
liab alit judgment,, i 1 p :- h h 1 n any y gI
against t + /
C> City' usestacnce of the gram ng of this permit. I _
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT \ II`
URCE RE T ) s. c. pec Issued by:', " Da
Sigmund ofli 'FCan'room a '. Date ;'Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the a Be r r r t b-Iding aacupam score on o dl b 1 n t al 'Type of Roof,
as defined by the Cupertino Mn ole pal Code,Chapter 9.12 and the Wallh and Safety' -
Code,Section 25532fa)^, - - - -
oYm., - - EJ No AlFroofs shall-be inspected prior to any roofing material being installed.
Will the'applicant or future building occupant use equipment or debieeswhioh If a roof is•in4alled without first obtaining an inspection, l dgree to,remove„
emit hmardon,all eotnaminants as defined by the Bay Arca Air Quality Management - -"
Dimino, e all new materials;for•inspection. Applicant understands;and will comply-with.
❑vee ❑Na; - all non-point source regulations.. ..
I have read the hmvrdous mancrals mquiranlents add,,Chapmr 5.95 of rhe
California Heahh&Safety Citde,Scerions 255115,25593 nm125534.1 unduxtund that
ifthebuilding dual norcurrently base atemmt,that it l's my recta nsibilitym notify the
occupant or the requi remains which must be met prior to Issuance of o Certificate of
Signature of Applicant„` `' Date
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- All roof,coverings to be Class "B"or better `
Ow agent Oulu � .tti - � ,t
rau tnr c a + � - .
OFFICE