01050162 CITY OF CUPERTINO 1 " ' `" -
BuiLmNd DIVISION' PERMIT . CONS RACTOR.INF�,ORIVIATION
r BUILDING'ADDRESS' ' f . J PERMIT NO.' .
EE116 CLEARCRF_EK' Cr
OWNER'S NAME: APPLICATION SUB DATE
SRL.L.ANs:Dt] 1R:aD - -
PHONE. , ' I' - - ' - '-'- SANITARY NO. CONTR -
OafZ ARCHITECTIENGINFFR: - - I BUILDING PERMIT INFO -
00
u❑ ' ' . . ' BLDG ELECT PLUMB MECH
LICENSED COM RACTOR S DECLARATION
Job Description.
0 Z I hereby ffi m t l 1 aW d p f Chapter 9(tomo ng P t
qmC-K''aGpo H.fOv
,.
with S ft 700t0)o " 9fthe
I, fall force
soa LicensecW.. e_-
Lid ee- _ a,Erff
3 `-
DateREPRLR�,';IF,T,.REPAfR-
CIF _TNE r IJPL
c%wo 0 ITPCI SoN
I a d my plans hall be used publi
,
'Li......d Probe.. ,.ul OWNER-BUILDER DECLARATION
'
r a
't i
w=
It I-h b,affifirm dent 1 am v.vai I m the C tinct License Law far the '
Z�Q fall "
,action.(Soof 7031.5,Basin d P f ,ions Cral Any vity or rur ny ' t -
E which marines a permit to camormct,
after,improve,demolish,or repair any,e¢ucmreai
i 3 m prior to its.. Iso ne,neer,thrapplivere for such permit file a signed.statement
ther hc I,licensed p II the powif,mr,ofthC t L (Chapter9 S Ft. Floor Area 'Valuation
(c D
g with Section 9010)of ', 3 f t B,s n d P f scions Gude) g' _
or that he I,r,voin,pt themlrnm and the fau,ifs frame alleged cricantwimn Any vi dation -
ofSection 90315 by any applicant for a permit suacces the applicant a)acivil penally - ,. �,,
of mu mu thdn rive hundred dollar,($500). APN.Number "'Oec¢pa
°I;ns owner oft he mupennonny etnployccsout,sieges asmeGsolc cmnpenea,ion. r _ L•; 1
will d 0 k and the , t Iintended ❑ d f - I (S 7044' etre .r. n .
Baronessd Prof .e' :C d Th Contortion:License L does t apply to an >. Required Inspections
owof property Whol Id p' h n and h I ' f k himself
nthrough l employees.provided that sh arprescurant,mr,notor
offered fIf,N,1161,1,the hdldg ,,improvee 'm" one you, [IIIbIDATI°ONS
,
completion,the b Id will have the burden at proving that h I'd oat built]or
improve far um,cwr rp`m1e 1 31 -,� ; ,CHTNNEY RE&AR"&,4vr TgRAG.S.„i(:
°I (if the property, ire ely rtnurriclang withl . e contractors to 514.: -'SF-INALi.'•PURI:,-I•Cw.WL7RF<S ,- '
Lolel to p 3 t(s 70a4 B : d Professions CodTI Contractors
i : 1.a,does net applyt fp p ,y who harld,or im,no,asmaroon.
andm
who a nhk far:.an probes with a c mnanl ds)I m am
nsed punt to e •,_
'Cnnandare s License Lay. - '
°I an exempt made,See - ,B&P C far this at ^
Owner Date �� 01NALED
WORKE 'S O S
- R. C MPF.N.AfiON DECLARATION ..
s�I
hereby affirm under penalty of perjury one of❑aefnllow'mgdeolumnvt.,, '�A1 2 9
,I-nave and will maintain a Cerancala of Conneni to self-hunm far Worker's.
-Gmp :'t- as p ded fon by Section 3700 of tire L bo .Cade, nor the
performance f fla,workl which lhis permit I,maed, " ,BUILDING
F CIIh e� t ill , t w k .0 pe t' I q ' ah 9lium _
37 f lid t e 1 b in Cal Performance
m er T
i,
I MYW C f 0 Iccarrier
nu
y
Corr er'. ryr ..Policy Nn: ,4,. _ ..,'• ...
CERT ICAI'ION Op EXEMPTION FROM WORKERS - '
COMPENSATIONINSUI2ANCE
_ 011h tion need.,,(be ciar,leacal if the penult is for one hundred dollars'
it ..
1 certify that ithe performance ofthek for whichthis peirrit is issued 1
shall mol employ any[wracm at air,men r so as In became-art c t to the Workers �
.,,Compenmdon Laws of Califn am Date
.. -Appheant -
NOTICE'IOAPPLICANT:If,aner,maka,this CerlRieme cr Exemption,You should
,become f,,lto tbe kc,,C adireviam pnewrour,of the Labor Cale,you must '
Q forabriall comply with irch provisions(it l .pental shall he deemed revoked.:
1
CONSTRUC HON LENDING AGENCY
I aciebyeffirm Ina,more v a construction lending agency Ionhe Verfrrnance _
� bfthe work for which m permit s issued(Sce 3099 C,v C)
Le We,s Name
Lande,'s Address
rafVv ..
hat
- ' cee hea :ld
tt 1 bvetf 1. t
W eorrec, grledply th pytyand r 0" nesand.t t :relating g
inn 1i do by representatives o[Necity iners upon
.the above
- fionod property r ec p sa9i ,(V ) b t ane fy andkdep h the y lCP against
-
j 1 :1 psi which vY a my way against aril
City e rq lh aingelae permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued REGULATIONS
-O
-
by: Date
Signalrre,of Appheant/Contramor Date - -Re-roofs .. -
' ' - , HAZARDOUS MATERIALS DISCLOSURE
r
Wll he hy'he)Eamon M nlr occupant ret,add eHeamote mmeem Type of Roof , -
as de, by the 32m)1nr Mu i i pal Cade,Chapter 912 and the Health unA Safety ,
.
Code,Section255320)P �
°Y -` °"° Al] roofs shall'be inspected prior to any roofing material being installed.
Will' tire applicant or future building occupant n.e equipment or drviers which If a roof is installed without first obtaining inspection, I an ins agree to remove
-nit n rd : eon, t. dermad by Ina Bay Area A Q tY M nag eat g
ilt 1 all.new materials for inspection. Applicant undeistapds and will comply"with
C:1 Yes °N all non-point'soufceregulationst
. . Io- e n o- d t mi:repaint nned co-apter b 95 or he
dCalifirminlieallh&Safely Code,Section,2550525533 and 25534.1,ndarnand that r
if the railcar,does nal a...mly haven tenant,that it is my responsibility to noti ry the - _
cmof the requimmets nwhichm vl b to t prior to issmn ,ce 4d Cenifc m of
cuinat - - - -- - "
.Ocpancy - - - -
Signature of Applicant „'' Date
Ownu'or tmther,xed agent " Date -All.roof coverings to be Class "B"or better -
t OFFICE _ -