01060016 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: - APPLICATION SUB DATE
' SAN1 ARYN . CONTROLNO.
O O ARCHITECT/ NGINEER: BUILDING PERMIT INTO
Fz BLDG ELECT PLUMB MECH
Hai
CI CJ CJ G_I
ozya Ihawb fflCmaEDnONTsedunOR'�ECLsofChaaN 9mommemaing Job Description _
L:w wiNSeden]Om)of Division3ofine Businessnder and Professions Code,andmy,license
xad yJ a in full force and affect
Ow< License Class. Li<.n * NO CONDITIONS
ce o• Due Co..",
ELL
a.
0, ARCHIT_crS DECLARATION
,� 1 understand my Plans sh,ll be used as public racords
Y
x o O Lensed Professional
`x$u - Oat I am exempt
from
DECLARATION '
w-m 1 masonereby,
afilrm thatI 1. cBusin from the Conten,Crete.
License Law for the
F? following reason.(amnion]o LS,Business and Professions Code:any city structure
.
e F O which roquircs n permit re cores the alar,improve.demolish,orrepairany swcmrt -
v
i 3 P t °s a also requires theapplicantof for such conamnntt is ug adstatement.
mih GrogBeldpursuant ectionamlpronmonsn3oftheoncmr and LawonsCod9 f'.•;-,'r, Sq.-Ft-,Floor Area
(commencing with Section and Division tebeausoteaBus yy dP .Anyv Carel :.F_ ,.t .l Y,t., , :' >,r � :tit L) \ ' E$7yquation
or rani he s 31.5b ,hercfmm and me bpiz for tbj alleged hempi oil.Any itplavoiof Section]thLS by any applicant fora permit subjects the applicam m a civil pemhyppppNN��77,Uor not marc man Eye nnwrcd aollaa rssml. - 3162804�mh 1, ancy Type
❑L se owner of the property,or my employees with wages as their sole compensation,
will do the work,and the swcmra'is not intended or offeied for tale(See:'] ;
Business and Profess Code'The Co macro License Law docs not apply m an �R�a�L,,'�'�r��f1C` ^•. _
owner of property Whobuild 'mpro sm eon and whodoes such rkti self 502 — FINAL PLUN9MGin
—�sU'Y
or through his own ply provided that such improvements tintended o
baaw for sale. f.however.the bulldi g "mprov t Id -tin' ona year of '506 GAS--TEST" -
'romplauoq me owner bu Ider will have'he humten of moving th t h did t build or
rov.
impfm parpom or sale) 507 FINAL PLUMBING
O L u owner of me ptopeny.am exclusively contracting m I cerrsed co manors m _ .. ....__ _.. .. .. _. "-_-
camrver mel Z/.
Project laps )014 Owner . d Profession,CW :)The C tractor's
t. 4crnu law lah wt r c m mi m,. f propcnY 'h leu Ids s Proex thio ha
.and who cpmm«a for soch.proltts.wM.,comracwr(s).licensed purwam to me
_ Comm a.z License law. .. .. .. -
, : sa. ` .' " ;B&Pt for alisrtaaon
❑1 am exempt under
Ounce 'Datci:. .. .
WORRIES'S COMPENSATION DECLARATION
.IIhereby affirm under per I of perjury.one of me folbwing dalarations:
I have and will maintain a Cedifinm'of Cori to self-hour,for work,i
compensation, as provided for by Section 37m of the labor Care, for me
performanm of the work for which this pamdt is izvucd,i.
❑1 have and will maintain Worker'%Compensation Insuram as required by,Sectiont. _
37m of the Labor Code,for the pndaemance of mwork for which this permit is
is d.My Workers Ccm madon lnsumM,artier and Policy numberare: '
r ..i...
Cam 'I I PTIO 11
'.'CERTIPICATION OP EXFI.N INS PROM WORKERS - _ ._ ., ,?\..Lt.1 (�r p FV.i\1,�;,�i.\\. s i.•N: 't. :.
. .... _..,,,::COh1PENSATION INSURANSE:,,,, ,
ffh- seri on fiend not be comphuca if the permit is for one hundred dollars -\ T:!�'t 1,).;(I tr.. Ci•
(Sim)or leo.) .
cenifY mat xh part ntt f m ork f h h m s t , - •• • ...•^•.� ,.•_
shall not employ any Parson in any mi av id becomsu
e bject to the Worked - 1'-r.7�.. "•'}" t
C mP ten Lawz of C 1'fo D t - "
Aliplierin,
NOTICETOAPPIIC\NTIt n Wg,h Gen
bc tees b ntom wort Co
C Z forth th )` 1 with h P,o th mto po irons Otte lobo Cal you mutt
t
Z 0 comply"' p - npcmi,shall bd d okd
CONSTRUCTION LENDING AGENCY
a.I hereby afim that ert'. cont construction lead fC g yh prfm p e
—
y%,..: of the work for which th perm i s issued(Sec.tW] C'v.C.) -
: Lenders Name 30 -
- i1- Z n rl en that 1 have read mise licetion and
_ 0 j* canon.1 agree to cam I city ware ma the above information is
U gree p y with all city and aamaity,
mpm ordinencea arta stay laws relating
" �-O mbuildingconswetion;and hereby autAorim rtprcvcnmuves of thiscity to enter upon
L A. me (we)
agree oo saw;and for ify and keep
p harmis.
p. L` (We)agree ro saw; a d 1,,pa and kehi harm,in a c City y.Cupertino against
?b city in co judgments,ems and apanmz which maY in any way,,ttme against said
V Z City in consequence of the
- Nof permt.,APPLICANT UNDERSTANDS AND WILL C°\P
LY WITFALL NON-POLVTsovacERECUATIONS.:, : I
Issued by: Date
s,gnatureof ApphcanVConvanor. rDae: Re-roofs
HAZARDOUS MATERIALS DISCLOSURE "'..'t'
Will me applicuail or futurebnxdbg p t m ar Howl hazvdpushearerW _Typeof
as defined by the C*hr o.M m 1pal Code Chaps 9 1 d m HeoEb and Safety ._
Roof-
CZ, Section 1557](1 t-. - , -T I1 ;� 'r •
__ All.roofs.shall be inspected prior_to.any roofing.matenal beinrt installed _
Will me,ppTocnx fru b'ti g«cP t mea P t ccgemh .i err - e ..
Di t ic= d z t as tlepn d by m Buy Area Air Quality Management If a roof is installed without first obtaining an inspec[ton;I ao ee:ro remove
°is all new.materials for,inspection..,,Applicant understands and will cote 1 with
❑Y .\ ❑No - . ... P y.-
' all non-point source regulations'
1 hale Health
thehay .d i maim L 50�iqremen=an d C p,r 6 stand the "\
=,Lha o Haahh s SafetyCode have
etians ant.that
myd 1x534:I understand mat
�ifthc building docQuirennot m, hitsmust be r:max it is myrcspobsi.f.Conotify the
cunt of me requirements which man be m<t,prior m iuuandof.a Certificate of
(
Occupancy.,,,
Signature,of"Applicant I Date _ _ __ _
Owner oramonxed"cal - o„m.;. All roof coverings to be Class B or_beite'i ''
.. t .,.. ..... - - --. . - -. _—.. ._...__.._--...
OFFICE
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