00080169 CITY OF CUPERTINO - -
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: - - - PEItMI'I'Nok
C400AMI 69
OWNIik'S NLW _ _• APPLICATION SUB DATE'
ZONE:
KHORSHID SANITARY, C1N'fI10L NO.
D z z ARCIIITEC'rIFNGI.NEER: -
�uOC❑ - - IiUILIlING 1'13kh11T INPO
U BI.W . ELECT' PLUMB MECH
a C1 1.I 1=J I�
� y
affirm
I J
L1 CONTRI DEC _
v;z ,CTOk 51 LCLARATION
z0 st= I nonny alum Division
I nm othlicensed under Pod Profe Of Chapter 9 ndm 0,cing Job Description '•,
F=h m _wish Section 71ami e f Division J of the Bminess and Professions Crnle,and my license
C In in lao,:rod etTeci., - ,• '
3 vaw note eclasx « ELECT SERVICE UPGRADE
a N Daoc Cnnmanor .
C u O d ARCHITECT'S DECLARATION
I underannd my plan.shall he sed as public record. ,
si
ou
�yaY 1
OWNER—BUILDER DECLARATION
v
I hereby leffinin b I I can evemin from oh Contractor's L Low bathe
t3x< fou g (Section7Bil.5BusinessdP f .- C Any city our ••
CFS wh n lem;lt ,vlrvcL tiler, ptn dcmr>I repair any stn cture
,
= Prirto its......cc,slsO icon,ties the uppl Load fill well flout to ltln usigned antcntnnt
Ewe` ..
IhatneisuremcdpursuanlmrhepmviannsofteCnntrennesl.icenalnw(Chapter9 S Ft. Floor Area
(commencing with Section 700)of Diviaon 3 ofthe Business and Pmres.inas Cade) 9• Y31Da OI
or that he is exempt rherefmm and the costs for the alleged exemption.Any violation -
ur$eetion J0J L5 by eny upplimm for a permit xuhircv,the a,plicunl ,,a civilpenalty -
arOut mareOmnBvehundred dopar, S510B. - APN Number Occupancy. ype
❑1. . tier fm p pent f" pl Y will) g theirle pc tion
is Il d th k d t t o t t 1 1 R d r : (S 7614
t v I Pole,sicon,Cadle,Tire C t :Lficmwi Law 1 I pply n:an ` quired Inspections
awac,of property Who halt,],or mpnou Ih reon a td who but Inch wink h'calf
or through his awn employees.provided that such improvements are nut intended or - -
Offered for sale If,however,the building or improvement is.old within one year of 304 — ROUGH ELECTRICAL
c aunctlon,the nwneutholder will have the burden of proving that he did not child or
tlpml,lu,porpa.enIsale.). 501 — FINAL ELECTRICAL_ ENERGY
❑Ia.owner aftheMitsu :amexcm,i;elycontractingwithheensedContmetnnm 505 `— FINAL' ELECTRICAL
.
consumer the project(Sec.7M4,Business and Professions CW,:)no Contractor's -
License Law does not apply m an owner of property who builds or improves thereon, _
and who contacts for Such projects wllb a convusamo) llan,ul pnrxuunl to the '
Contractor',License Law.
❑1 am exempt tinder Sec. .11&P,C for this meson
WORKER'S COMPIINSAI ION DECLARAOON
Thereby aRnn coder penahy of perjury one of the following dedantions:
I have still will maintain a Cerdtimne Of Comeat to Sell-ho ore for Workers _ r
CnnfPsu,atlon, nx pmvWed [or by Swim 3700 of 1M Lubar Coda, for the
performance of the work for which this ponad is issued. s ,
X1 have and will maintain Worker's Compensation Insurance as required by Section
17110 of the[.shift Cale;lin the pedannance of the work for which this Moral is
Hund.My Work c'sCCA.
sCempensmiaAn inxurunee enrti�cr n�nJQPolley n(n/Qtnber
Carrier. CEWr C EPill TEh1P No ION FROM L RKrk"_76 s
h COM1SSI"POOENNSM'ION INSURANCE
(This section need not M completed Won,Permit is for one hundred dollars ,
IS 100)or less.l `
1 cerhy that in the performance of the work lin which This permil is i..0old,I •t - -
shell a"(employ any perenn in any not ner m us to herons,
subject m Ibe Workers' - - -
Cnmpensao Lii.s of Caliorm..Doren '
Applicant I
NOnCE TO APPLICANT If.idlerl this Clum Relan Of[somptum You should -
,�' .heloole,olopeL I to the Wo our Conal
t p' fth 11 Cd us s
Q I mOtw'Ih on Fly Inds w�'nm n it mmi l shall had d rovnknL ' -
E„ CONSTRUC ON LENDINGAGENCY ,"•
a. 1 hereby Or.that There is a consumed..lending units,for the Performance - -
til the walkfor which this Mormt is issued(See.3007,Cr,.C,) - -
7 ❑ Lcndu's Nanta
z Lenders Address .
IhO n rc 1 clod I,that lM1 e I'h' Ppl' t d tt throb M 1 'litits
I ince ro
0-V t:badd' gc utnnion iy mal hereby inflationrely eddif",Of Iliscl wericrlo ng t -
,�. Rt the above-mentioned property for inspection puvlj cs. r pm
0. little)time
to rare,indemnify and keep hnnnless the Ciry of Cupeninn a4ains '
Vi liabilities,judgments,caws and expenws whicF may in any way name agninso said
6.1 City in eOnsegtm"'of the grunting ol'Ihis permil - ,
APPLICANT UNDERSTAN VILL COMPLY WITH'ALL NON-POINT �. - ,�/-p Q^0-
SOURCERECULATIoNS Ll Issued by: •� Date O `/
Signature Of
Applicanvc: Re-roofs
HAZARDOUS dxrldUAI.S OISCLOSURC
Will oh i applicant ur furore building occap:ml:rare or handle hazmdnaa nnncnel Type of Roof
Is defined by the Cupenioo Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(u)^ 'El yes El NO I All roofs shall be inspected prior to tiny roofing material being installed.
Will he at.....nl inand,auture building a:appntuw equiir Qtnmdevia•s whim If a roof is installed without first obtaining an inspection, I agree to remove
onto hazanlohe air co ant Or fns as defined re the Buy Area qtr Quality Manegement i g
li"nCr? PP
all new materials for inspection. Applicant understands and,will comply with
❑yes 0 N - P
all non-point source regulations.'
_ I have read the humrdous mamnal.c requirements under Chapter 6.95 of the
California Health&Safety Code.Sections 25505,25533 and 25534.1 undemm�d thus
fthch Idm,d t<utremiy have vonum ihoil 1. y spa n'b'Inyl n ify oho
Ocup. I ith y'en nIp hob nst he tp' rC of-ate C "-- -
wI pa y •,
Signature,ofApplicant Date
Gwner ra r ' Dwe - All;roof coverings to be Class "B" or better
toiT