00120157 15i1TY OF'CUPERTINO -
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BUILDING D[v[stoN- PERMIT CONTRACTOR INFORMATION ',i ,
BUILDING ADDRESS o PERMIT NO r ;
1.(isix) cnF.,nic nV JLJM' �MTT:ER 1-I[EATE R!i3 I11,1C, 001t. d1.51'
OWNER'S NAME: - - . APPLICATIONSUB DATE
"S WD FAJaWlI S 1:764 wwri:014)L. f-1VE. 1PA-1:1/%000
PHONE: SANfLARY NO. CON I'RUI.NO.
(5:1.0)Ex.`X :..4 NJ.
ai�Z ARCHITECIIENGINELR: - - - - - BUILDING PERMIT INFO
0,0 - . . "• BLDG ELECT PLUMB, MECH ^
W F.
z5y& Ine'eny am��m�li„n ilN'fRAerORcensed andr,n DECLARATION eeri�mennenen - Job Description _ '-
7-lz will]Section 90007 of Division 3 of me Bu andPrnfes, sCode,:hd toy It e
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a a r Cand offer,.
eig � is Class
far,x F E1='L.fIfJE 40 0XV 1_C1N Ca.3 binTM H17-IT17 r
3 u H Data Co nracror \y , _ •�.
O 4 ARCHITECT S DECLARATION
N I d1 -
y from, M.used a public acnrd, U
,o O
Licensed P Nlssional
OWNER-BUILDER DECLARATION r• "c '
`i or I hereby affirm that l ad exempt ficam h C 1 r Loceree Law to,do
�4
following (Section 7031,5 B :' d Prelusion,Code:A y city county
' C' ,
S O which o"mods a wunit court rear,aduar, V denal-.1 p'' day structure
�3$ pro , 1 al. y Ihapplicantl hpe ',t fl g J-1] on,
moll licensed Personal I the poll of the C 1 L L' 9 S(Chapter Ft. `
(co a ng with Section
exe rIa runabout d 1 90001 f D' n 3 f lh B d P f,d .Crave) ° Q' Floor Area Valuation.
a t' '
or that he Ir f ,h alleged pr An, -nlaread e
of Section 7031.5 by o y Ppl ]l bit-a M .1opev,h[app] tm m a e.v l penahy -•1>Ed�'"i•
other more man fivelnndmddllars S5R0) I APN Number - Occupancy Type
Cl Its owner me property,or ay employees with wages us their sole m.npema,icar
will d th k d Ire a -t re Ix n I intended or offered f alc'(9m.7044,
liRequired Inspections
t laid ' Ih Chummier',t . L' L e ] ,apply It, .
ownerf property Wh brims p e theme,aid who does such -work himself.
PLUMING H+ 1�1�q C�f�V
or through ti:own employees,provided that rh improvements re nm mended or �j(%]L •-• F'.[ISlnl._ F'1_l.11 4ING L'J`YERG 1 „
Mitred for ed,If,however.the building m In t roveaea is fold within one year of '
melpleum],the towner-boulder will have the burden of proving Thal he did nen build be '�Pi@6 -•• r./AS I1:AJ 1 ,
improvef......d of ). .
l ,n'r07 F:[N(ll_ F'I.AJ1yIB:[Nii
El Las f the property,ant excIsvly contracting licensed d' tatur,to - „)� ,
nt uh poder,(S 7(94 0 dl I .-Cd)TM1 c , car.,
lconsumer
odife Law does notapply It) f property who builds p e;thercon, - u
Counters',hLicense hor h projects t t r ()licensed p : to the
OI npr under Se. - B@PCf this �A� r
Owner Dol
WORKER'S COMPENSATION DECLARATION
I�. hereby I f border p Ir y f p p } f flad e following d T r u. _
❑ ,1
� I b 1 II t C nI' r f Center., 1 f •Wo Worker',
t Cnmpe:I' p 1 d for by Section roll❑ 1 II Labor
nor Code, for ,he
pert un a of the wo A for wh eh This pe tit is'ssuaA.
011....the
will maintain or the eCompensation re work
k f as rcyuired by Section
37110 of the labor Code,for the performance,ar , work for which this Penn],Is
abed.My Wnrkode Cnn]pcnsvbnn Insurance arzier:mA Policy5ntmbv arc e
Carie': Policy No.: +,
+ CERTIFICATION OF EXEMPTION FROM WORKERS' .
• COMPENSATION INSURANCE '
('ILivscmioh need not be mandated if rhe earil Is f..oad haidred dollar
I certify but in the p i ame mfund d,kf h' this pe 'I'. .:u J 1 • _ '
shall not employ 'try person a y ilannuar se as In bull ne subject to the Workers'-' -
Cnmpeuaa]LdweolCalifornia.Data
-
Applicant
NOTICE TO APPLICANT.If.vl e,mvking',his Ccdifiet a of Exemption,yourchould '
bee : nj It ddW k Cop t I nreof the Labor Codey a .r" '
gabosll comply w,Ih. bpmsm]sonlxpnn'l shall he deemed rcvtoknl, . - is
E~ CONSTT
RUCION LENDING AGENCY
a 7 - I nod,all em that there e'a n.t Ion lending ugency fit, pe rcmrvdc
ofm kftr which this Palin]is',sued(Sao 3097C'v.C) .t
W Q Lebd
Name
.r, z Le to,',Aid est. ..
I comity that I have lead his a,dia.ficanads1 That theh r mil s " -
GN Fy tt)rrc 1
area to ply with all city and uhady hamena. and vote law, i(ng r
u� V tobuilding construction,and hereby truth - reprise 11 tr\es fm sCty lin eri
ti4the'b i .aid for rely for 3mb 1 parpreas, }•,
(W)agd.s,to ills indemnity landA p haddlexi the City of4pm g ' .I -r .
Vi linti iflal, m,dada1.101a'and orboadws alach may in any way accrue against.said
V Z' CIIy- g o
y encuof,h gentlinf lit,P t'
'� APPLICANT UNDERSTANDS AND WILL COMPLY.WITH ALL NON-POINT d b
Issued SOURCE,REGULATIONS.,' y: Date
'Signature itfApplicnnUcamm�ctor - Date Re-roofs' , d
HAZARDOUS MATERIALS DISCLOSURE. _
Will the applicant or famrebnuding creepier store or handle haaareianu material '`Type of Roof. r
us failed by the Cupenino Municipal Gala Chapter 9.12,and me Health and Safety -
Cade,Seerion 25532(x)1 t
❑Yea - ❑No - All roofsshall be inspected prior to any roofing material being installed. •.
W'ethe plfi a 1 it,blame bI ,a,overran,use ccrithforril or device,wn n If a roof is installed without first obtainingan inspection, I agree to remove
chath' . d r Iia der dbyd eye aArQ lr,M g -, ,P g
=I 'oY oN all new,mate{ials for inspection. Applicant understands and will comply with
all non-point source regulations.
I face read,h'hazardous r rey orcolor Chapter 6.95 of tire
California Halrh&Safety Cod Seeltons 25505 25533 and 25531.1 unaricuthad han `
4 Hiho huildngdocsn......nllyh.vearnmm lhn"t"xlyrw" mbilylu... fy the `
occupant of the decimations which roust be at prier n]issuance of e Candidate of
Occupancy.
'Signature of Applicant - .. Date -
ownertoroamnrneJltgem ,Date All roof-coverings to be Class "13—'6r better'
OFFICE