00100082 CITY OF'CUPERTINO -
BUILDING DIVISION pERMIT CONTRACTOR INFORMATION
BUILDING ADDRE S' { 11' ) f
10530 'CASTINE AV. - ' STRITE ROBERT E ANPER6ATHIA?,A00100082"
OWNER'S NAME: " " - APPLICATION SU 1 ' -
STRI,TE ROBERT;, E_ AND; ( YhTWtlta A :� .11/20001
. PHONE SANITARY NO. CONTROL NO.
O z Z ARC] IECT/ENGINEER' "r- - BUI ING PERMIT INFO
O❑O❑ ' `,t-•. BLDG EL T PLUMB MECH•.
Lr
U n. v 4 • I—I T� - ISI I'�1
Z O N.ZLICENSED CONTRACTORS DECLARATION ...4' n E ,1017 DC$C17ptlOn J
Ih R by that licensed'td p if Chaplet I nwemg ' _
r4F� wins r eEOE) rD ofineBl tinProrr.gl setaea,amyre nELECT CUTLETS : '
�m��, t.i fall force and erfe<1 • � ,
X�S < L'm . Class
Lm M -
ak 3.a a Date 'Contractor -
,e O G
ARCHITECT'S DECLARATION
" 1 d to f ,'line'.I all he Lead i p blic rcnrtrls
N
' w�p0 Licensed Pfss oml �.. - a,.
OWNER-BUILDER DECLARATION
�. = I hereby alFm,that I am.exempt from the Conor rat r v License Low tot II .
t�Z Q fisilloomic,reason (Scio 19031 5,Bus ic,, I P f. Cod .Any 7y county
Sa p whi,ti carries a bonalito,construct,aIle p dtai r palcity-tructurc s
m 3
Prior I.lal 11raille,.11.raaflaisvl tire applicant for L 11 partial tg a statement ••
thallic is licensed pt,standt he provisions of tire Contractor's License knew Cooper S F[ Floor Area Yalnatlon
(conmac g withS t 9000)of Da, 3 to B . dP r.' Cacti �� $0
or matbe is rsempt thf 111 b f m Ilea al L Any v olahnl ] .. r
of Sect on 90915M1yu Y FPI'" tf - pe it lbje'cts the apps sold to a civil Penally ' 1
onto, pore man five hundred dollar,(s50o). ..A'PN Number . -'Occu ane e' '
32644040. 00
;Occupancy Type
1:11,as owner of tire pmpeny,onnY eo playon,with waees as their solo eompmsarnn,
will d thk d thetru to t intended offered for sate(S ]044. - -
Bn me d a r.. Code:TheConnector"L1 ae Les, I e. f apply I , . 'a R%t ired'In5 ections '
rproperty Wl 1 'm: 'rip sees thereon, a I l work self `t t 304 — ' ROUGHLEpCTRICAL .
orthroughhs wne,plye. provided tl I. h'in, l. : lIorient fnr ..
offof sale..If.ho the bidding npmvcncnls.old ssipar rr roe : fit. 501. — FINAL 'ELECTRICAL 'ENERGY '
- ompinonmeowaren 'la 'Ili have menyme,orpovlgthat hdid f<,lnaimnr 1505x,— FINAL. EL1 11
ECTRICAL.t'
°1,as ewnerorme pr peel) I :vly connecting 'th l'e Ielcal mrs to 1
con tmel the p 1 t(S ]044 B d profession,C 1 )91 C t em's s - '
`LicenseL d eplyI ]P p ry h h Id p charter,
and 1 rono-ads for wh r gens wah ntmuor(s),I n W pursuant m the
Con I ,LicenseL ,- -
❑1 po derS Bc&PCrnrdasr t 1 -
O'nor min s,
WORKER'S COMPENSATION DECLARATION'- •,`//'1•. '
Y
•. II by rT dip 'Try fP ) Y rine fr 11 Sd P i
❑.I h 1 11 a t a C n l t r Coast t I f for W ke s
Col p I a.,pr 'le I f by S I 3700 f the Labor r Code, for the
' peel Inmate of the wo kf heh tMc pc ort s ssueil. c ��� '
• °I have and will malmaln Worker's G,mliewviondnsmm�eo,os myuiful M1y Seainn' h t ,
139W f fi Labor Cod thepe f 1:nce of the work for which the permit is -
x1 n.MyW kcr.aCmry. in 11surave carrcrald Policy nunbcr arc.
; .
Car'- { Policy Nat u. ..
- CERTIFICATION OF EXEMPTION FROM WORKERS'
• •COMPENSATION INSURANCE
('Th ion need air,b cnmpit n 1 f tlp nil is roar one hundred dollars
IS 100) I es.7
... .. 'n -
1 ntly th l' It p f- Ilea kr r hich this Pe I' issued,' I r
shill I yl Y- .. in l lo +me bj n m the,Wo kerC
Alarboanlaunn a at 1 t r `
NOTICE APPLICAN f IL'ft g this C t f Excitation,y houla
'come
jct1.theW k -C p i p III L.bor Conic yrn mull •- ` r �' " I
. .� forth t c nply with, h p :Inn or,th':p n I shop lir teemed 000k,d
.� ti `CONSTRUCTION ILNDINGAGENCY
sl l chyaff Ihnh t f Jng.gcncy far the profs mance
W filework for which.thispc al's fell(Scc 10bD Cl,.CJ '
LvxW 'Na tic'
Z Leaders,Potatoes, r,
U � 1 Ify thatlh e duh': ppl'rn ad:fare danh h f I - •
torr t Iag- t fly with II any d my Jinn I state I t g S '
toBuilding :n f and hiautho rep et_t s,t thsetyle enter upon - ..
W
no b n i dproper,e :P r Pep -
i'6t (W) 6 t I fY keepdM1 les the City fCupertinogist 'Gr
ti V] flubll . dg 1, is i p which try 'a'anY Y 1gae,r 'd'
U Cdy co , cnfth g' I got n
t••t A LICA D SfA D se it C MPLY WITH ALL NONPOINT '
uRc ,uL 10 - ' h 'Issued by Date
St are PiCpprnlvcnaewcxv �. nate Re-roofs
HAZARDOUS MAILRIALS DISCLOSURE + 1
Wun ppream ret b m' s p Ln handle h I nn 'dl Type of Roof
as d Secure �Cape l Municipal Col Chapter 9 12,and theHealth a ld Safety , Q..
Cad Secure
25532(el - s " r . •j'
°v r °N All roofs sha e.inspected prior io•any roofing material being installed"
Will the pl' I ft blJnb c rL t equipment d wl h ,
If a roof is installed without obtaining an inspection,1 a tee to're1 obe
Dill hazardous a�I tofu le as acfintA by tire Bar Arra A Quality My egunem - g P g , p
District, 1 : " _ , all new,-materials for inspection. Applicant understands andrwill comply with
❑Yee °N" all'non_point source regulations. :';t,
Int
read the.hazardou.vmtverials re"Lle rats boder Chapter 6.95 nr
California Health&Safety Core Sanctions 25505 25533 and 25,534:1 I t dlr t _ ,
T1nChl,lang anes not currently have,leaned,that I' yresp nlI t nryn - .
Feynp,n,or Inv re C Men n I p I f a fieri teen of v x.F
Occupancy p '+ , - -
Signature of Applicant Date
)finer thoazndagent -• ' nate - All roof coverings to he Class "B or better
,
, sr r