00070101 CITY,OF CUPERTINO -
BUILDING DIVISION: •
PERMIT CONTRACTOR'INFORMATION
BOILDIN16110550 CASTINE AV - 'JUST- WRTE BNMffry
OWNER'S WYgINSON STANLEY H :JR 1764 ',NATION APPLicAT S I l '
293-991F' , "+., SANITARY NO. CON'FROD NO
O K Z ARCHI I'I C'I/ENGINFI W •a 1 BUILDING PERMIT INFO
- of BLDG - ELECT PLUMB MFCH .'
d
o '
yz
LICENSED, ise aAC90R S DECLARATION' - Description - -.
J
z.5 _
az In nr rr mmll 1 d p ' ren pt 9( ag - ,p .
an Set erect fD m9nflhn Bu dP N.:i Code and nYl e '
¢ $ ni lull r < anti b u a Z WATER' HEATER •
Ise K 6 Li t Claa ' ,
3Dvt Can,vamnr
ce to ARCHITECT'SDECLARATION
cey m to - 1 d I J y pl hall be WSeJ a:public J
ay Y
c.sy�
Licensed 1 na r t
OWNER-BUILscaDER DECI ARn'110N { _ a //
=' 1 hereby a0 rm that P m escapist f thef m' I I 1' f the . r
k Q w m x (Settle.7031.5,0 :' d Profession,h d n Y cry re - P ` 0
Sak o wh h permit I construct, h p J l.hminatory t l
`prol 1 I q IM1 ,ppl'n tf hpermit l 11 a'Fn dstatement
,n,tn licensed- pursuant t theprovisions f the Contractors Let La (Chapter 9 Sq.'Ft. FloorArea Valuations' -
Ica m enb w In Sat on 70011 of Davison 3 of me Btsmes and Pn fws rsCnI, _
or that he is exempt therefrom and the basis for the t Ile ed excerption.A satiationa _
P t, b rim $790
of Sectmn 9011 S by arty applicant far n p t nl+lems the rpplicrm I u civil pe Ily
of net mom had Fee ht adred delfars($500).1 11 - 't"AP 2610 Number - Occupancy Type
'01:as owner the property,car my employees with wages as their sale compensvaon, �' QI� .k,' 1, 4
will do the,work,anti the stracmm is not Intended or ufferet for sale(Sec.7044 -it,,pass and Pml.......Code:The Camracmr's License Law does not v to an Required Inspections
-
rkhi qu ed
ratpropcity ad I ,a Ih a d h ten If
arvthnm h his awn em I e -� n
s , p tr dedtnrch ..provenoldeithanimenaeanr 502 '—^ FINRL PLUMBING ENERGY
coulpol'or srle.9f m-am
the Invelm coven en ..x114 ,
"It t' wllhin the ear of
x or y. _
m Ietiun,the owner-huildcr will have tM1e bnMeti of r, n�thm Be did not mild or -' _ .ST ' e •
np p ;�ib :506 GRS',TE ,
Improve for purpme or mle.l. ..
is —
507 FINAL PLUMBING'
'❑l,vs owner mrs property,an, I .'el t 'I x th,licensed contractors . , -
mcnuerthe armed(Sae 7tow Bts o and Professions C(dc)]hempr venth t -' -
1 icenxa Law does nota I man nwt end r,en who bu Ids or improves vs iherun `
and n contract,lot ate h p ojectn with n connnmor(s)licensed para am t the
l3leaccoContractor'l aa.me Law. - _
❑lanexen tunJer Sec: ' ,B&P Cfnr thisreason
P
Owner p ` nDate
WORKER'S COMPENSATION
neDECLARATION
I rte eh affirm ander PerchY
'
-
6
u
a'
❑ 1 have send will ur ideal n Certifc Section
of Consent tine L insure foo Worker's
"Con p -'f -p nv dal for by Set s issu f tire Labor Cale;Sfor the t"
.p�ed� voce nl the work for which this penit is'smW
y'I n' . J 11 ''m ' \V k Compensation 1 , requiredhY Sof
3700 itr d,Lunar Code,to,the perform in a ce ar the work Int-wh ch this ,air is
issued.My Worker Compensation Insurance carrier and Polity number are: -
cardecL`,�AV.2y1'ney1. Polity No , Yj'R,QQQl4
CERTIFICATION OF EXEMPTION FRO WORKIiNS'
COMPENSATION INSURANCE t -
k
(This action need War be completed it the p arfNI is far(me hundred dollars g.
1 amid,that in he per fm ane f the work for wncl thispc rat'. ',' d )
l ar e
shell moa anpl ry u y per n my-ma mer, t9J�VQublat m the Nurkers
Creat' :?curt ,of Callum .
Apd t - r
NOTICE LICANT If alter nrkinb lh'.Ceri fate nfF ptiom you sn wlti u '
bee m cR th W faces Cmi,enwaimaprawkimetoftheLab C le you most _
�.� Q fool It _ply with such p sir nF oohs perm t chap de
be e 1 ked.. _w_ ,.
^F I CONSTRUCTION LENDING AGENCY 1 -
I dap,hy option tl nl ..colon cadnF ,,day faille performance ,
of thc w k for which this'pcount is issued(So,9097Civ C)
a,,a hen tern Name
,f, z Lcnd Addr s "4
Q I nee to c comply
re appl m o d o t nus sh above la
W H cormel 1 cont IY e city d CrannyordinancesJ state I : t
Q [)• can dd' gc t i dhereby
all
bb y tl p ant t fah -cit,to mr.,ad
U • J
[T] the thave prentioniptp 1 t for ir,pratiamnprp w
ar Val Inab'rt(s.])agree f.,rea,Ig 1 t add OthhY.Tyr dk ph , the any aywy a lel fn.i'ba t - ..� `
City' consequence of'he . w _n uFnst said
/ '/•.
gearing tk tfthis permit.
APPLIC NEcunnno UNDERSTAND AND WILL COMPLY WITH ALL NON-POINT
sou ' Issued by:
�.0 oder i- 2�!P/oo
reof Apphr AR •S � D�n�r— Re_roofs
H
HAZZ ARDOUDOU S MAIENInLSDISCLOSURE -will dl appream future nn tarns ora
pa amu a r nanme n.a t
mergers central ' 'Iype�of Roof - -
as d f J by in Cupertino Marmara pal Code Chapmr 9 12 and the Health and Safe,,
♦
Code,Section 255320). ' S` v
El Ye, 0-N t ., All roofs Shall be inspe rior to any roofing material beihginstalled. if _
h
W01 the Cpl t or future n if g occupant use equipturat or devices wn hIf a roof Is Installed without first obtaining an inspection, I agree to remove
emit Ions.. revnt na as refined by the Be,Area Air Quality Management' y ,
District?. *. all new materials for inspection: Applicant understands and will comply with`
❑Yes - ,-ANO.,,
I 'sl - all noti-point source regulations.
1 he e d the hazardous mat al q i mem Charter 595 f the
Cvl f H nh&Saf ty C d S t e 25505 25533 and25534 I 1 :t nd that
i ,
niffleebuildid,draw t whit eat let pri': rymsp s bil'p toratify ane, '{ 1
occa pro of the requirementswhich man b t,p'or m ossa f Cambium of e
oeerpa • Sigmtline of Applicant- Date -
�:.
rnrautnua:edo,ant' - , Dae - " All roof coverings to be Class "B" or better ,
OFFICE.:-