00080208 . ,.
CITY OF CUPERTINO
BUILDING DIVISION . 'TERMIT CONTRACTOR INFORMATION: „
;BUILDING yJDRES& ' - �+ o _ PERMITNO1>VNCR'SNAA1E:�� a APPLICAT10168 .CASS` PL. " CONDITIONED, AIRe ,+_ ° SANI I'ARY NOONF,:
RAMM'. 1640 G3LMAN..AVE Q18/c9�c tVJ
. necO ARCHI'I'F.C'pSNGINEER. ,. - ,. BUILUINGPERMITINFO
(408) 374-631. 1BLDG. ELECT PLUMB "MECH '
h LICENSED CONTRACTORS DECLARATION
Z o 4 a - Job Description
o a.�o In ny n' mu I . e e p rel-It 9( s P,
rte:-W N,nS
is hall irD 3¢the Bu ,tl Pmfisci .C Be and ny en. - n
nempanld•fln'1. , _ - _ 'v
� .6 Licence Cl... L'e.p 1
vi3o,f Dnc - cmt, a.
ARCHI I EC S DECLARATION
gaN$,y laderstand toypl shall be toed its Public d AC. UNIT -
OWN IR BUIL DER DECLARATION
' I hereby affirm that 1 ann exempt hour the Contractor's License Law for the "a -
I"Z6 Joll g (S , 7O3LSB o IF f,�' Cd Any city ly A r •�
dF CYO wh h e 1 ,I c " I .I,e p 1 I h p y o
3 'pro , I:I. I. reyu, In pn ,r n p u file signedOstern nl
that he is fiConsedP „ the tobvisions ofl Contractor i License La (Chapter 9 1 Sq. Ft. Floor Area Valuation''
(w y d Section 9000) f o' 3 to B d PrI :Code) `
err
that hp,thearchicau and the basis I the 11 S d p.en,to A ) Iwlun , -
'ofScirita,7WIS by any apascautf Pertunt. bjects the ifhapir„ ,aewtpennny -
oI nimmcredern fiOu hundred da sONo) �, _ - -AFN Number - - OcciTpancy Type
❑I er Of,he pro,ce,ar a,y re,do,ac,with ,gosns thca,ole nn,pen,atiam SE IOC
will do the k and the l ucu re is om Intruded or off,red for site(Sec.9044, - - -
Iin slid Pr field Cade: I he Cup,...can'tUwar,o Law does net apply to as - nired Inspections
nwnc fp P tyWh build, p th d h I I khirealf `
or tl mubn his own a npioaee+.pmv dad hat such'npawe»ant,an,ad,intended +n 35707"031.. I ... .
.
officird lot ale,If flat n luny 01 impollyporad is Id o c.ywrP of 1
o pl i ul h Id sell 1 1 fpovny I'th I'd nM b,'IB or '
mo forptrymcal ale). , 303 ROIJGH MECHANICAL
D I plelve,of thepropscuty,so,eselo,ived, inaloamarg ,it, : a mouLon,t. ' 304 — ROUGHELECTRICAL
v, Ion t the proper(S .EDT,Bos'ne: LP dessfoa Code)The Cnnim a,-e - t, - _ 1
License Law g6,not apply,a an owner of property who bnuds nr imPmvc,martian. 505 —''FINAL ELECTRICAL
and who coram+for such p Jetts with a ommeter(s) licensed pursuam to the
connatlo,.+Lictn.eL„». . 508 FINIAL MECHANICAL
Dl am exempt under see.. ,B&r c for mi.,reasin
owner - � Date 1- - . .
i... - .. ..,,
it
WORKER'S COMPENSATION DECLARATION *• - I
hereby ativm undw,am,11y of e,u,y o a of Wo toll w tg dalavl ons'. U • ,
I hose and -ll mana', Colifi,ale of Cup,ma to w1fia,ir re for Woks • pi, " I ,
Conpensaio, as provided Lor I ,Sc tion 3900 of the Lobar Code, for the
performunce of me Aml,far which Ihia permit Is issued a
❑Ihave andwll mom W kr:G,mlrea„o,Ins mnc as y ' dhS Set - e
3900 f the Later Crat f ,1 forma ere of the work f which this p t - • a p •"
s..ad,MIlk rsC i p nln.vrunm cu re dPol y lMram
Carr . 4 r Lii—"Soley No. o f '
CEIG IFICA'I ION OF EXEMPTION FROM WORKER •, ,
COMPENSAMON.INSURANCE -
(This section neI ,h completed If n permit is for one U ndred dollars `
(SI00), less) 4 P”- -
1 vi,nd,mt in the rafimarice ofiwork wood,,h Peru...is issued,I
e -
Quill'arm toiler,' y p troy insurer
is Io beer nsuport m Or Worker, Y '
u -Compensation Laws of C I f mm.Dam
NOTICE IO APPLICANT If. Ile k' g this Certificate a.'Exemption,you should
,Z lactore othcert par Workers C apain'stion Prowkipwofthel h Code,you amer
a.
for,M1 1h co,nply with a such p vii oOr his permit shall be 1 d ked. -
F,tiCONSTRUCTION LENDING AGENCY
a 11 by IT ,lot,lbc,a,,a con,procrico lemon,ri,py for the pctlarn ne
Ga 'if the work far which this Pena,',issued(See 3099 C'a C)
g, Lender's Name
Z Land. Address t "
V
Ipliiifyflualli ad Ink applicalid state that khoaldo,,irfor , a *• ”
wn d,.I agree to tonality with II city 1 parity ordurpers ard suite lawy,reSdag t.
V to building constitution,and hby authorize representatives ofthoty[center upon I•
{i�H the b - ' Isa e, ,y,f p t p rry e Re (We) 6g , d nmf espouses
I ..
ph stay
. fC pet y' t
ab
V] Iill dg , ,: I J p ses h 1 n,y in uny y reame ago n't said `
U City ) "t ence theg n ng I This pe I • `
APP A ANT U,D. T 11 WILL COMPLY W TH ALL N-POINT ^
so H F . o . � Issued by: + Dat
si menfApp eaal(Coanaemr - Dae.... . }- Re-roofs -
HAZARDOUS MATERIALS DISCLOSURE ,
Will da,rp,l,mt or tume buildia,camera,.t rhandle therciplaus-natidial Type of Roof
I,,cafina,d by fly,Cn,wO w Mione,pal Code Clivi a.I2,and the Healm a d Safely ,h -
Coes,Section 2553Ddx ,
11 ye., - E3 No "•_All roofs shall�be inspected prior to any roofing material being Installed. .r.
Will the.,,heart toome haddina.1copell aw equip, nt .1ral, , If"a roof is Installedwithout first obtainingan inspection, I a I'ee to remove
Ihtr d cont i ,: :d f nmlbyth Buy AreaA Quality M nage m• - p g
+t .1all"view material's-for inspection. .Applican't understands and will'comply with
°r' °Na u all non-point source regulations. -t• '
1 Ihd tl hazardous L
!)/ I t d CM1 pt -fi>5 f th
fma old I &SI tyCit S n s255,15255A 'd26 onis
lea tld t "
f t h hold l d e l , 11 t , mit Y P b l,y t, .""my
I fy m ,
eery t nhe rc I. tone" stn ,P no :. ant ora Cori feat 1 - `
Gea ,• .
• " �'=✓Z�'p� Signature of Applicant` 'r. Date
or u nitecdagenl n,,,, All roof coverings to be'Classrv`B" or better ,
Y