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CITY OF CUPERTINO
INFURMATiE)hT
BUILDING DIVISION PERMIT
CUNTRt�C Q1 �'o.: k-'.�x a:h�lr '
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BUILDING ADDRESS:
21J25 COT,T,TN(-eWQRTT4 PT
PERMITNO. 06070111
OWNER'S NAME:
PERMIT ISSUE DATE
Ak LANDO MUHLSTEIN JR.
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT ' PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
P
1 bereby •firal 1 am limnmd under pmviAons of Chapter 9 (commencing
m N
with Section Wray,of Dl .M.3 of gM Basin= ad Proluniaaa Cade, and my If== is
ce
I. fall rmandeffect.
REVISION TO ORIGINAL PERMIT #05090072
License ChisLk. i
Dam CanInCtm
REPLACE 6 WINDOWS AND REFRAME TWO OF THE SIX.
ARCHITECT'S DECLARATION
I understand my plans Mall de used as public mem is
Licensed Pndnsional
OWNER -BUILDER DECLARATION
1 hereby M. that I am exempt from the Cummetors Lima. law for do
following anion. (Section 7031.5. Business and Proresduns Cade: MY city Of county
which mquires • permit to construct. Aller, improve, damorsub. or repair my structure
Sq. Ft. Floor Area
Valuler aO88357
prior in its issuance, •Iso acquire the applicant formch permit to file a signed vacuum
Llaw(Clup9
the Contracmicense
licensed pursuant e provision of r's
Nal he ism N
(commencing with Soden 7000) of Division 3 of the Smamms and Profrsions Code) or
that he is exempt therefrom and do ball fm the alleged , pdan Any violation of
ApN Number
Occupancy Type
Section 7031.5 by ury applicant for a permit subjects Ne applicant in a civil penally of
not mart Nan five handmd dollas ISM
35617066.00
1, u owmr of the property, m my employees with wages a their mlke compensation.
Required actions
P
itill do the wark. and the sinclumlaan[ intended oroffered for sale (See.70W,Business
and Professd- ions CaThe Conaacton Liam law does Int apply to an Manor of
9
property who builds or improv thereon, and who doessuch work Mmmlf ar through his
own employees, provided that such improvements an not lnmoded oroRemd for sal- If.
� -
holder. the buildingthebrimprowmantlsaat IM didnamyur ofWmpleforthe owner -
builds W0 have the bidden of proving that k did nm build or Improv far purpose of
y�
aN.I.
❑ 1, ns owner of the property, am exclusively Wntrmting with Iimaed mrtr•mom an
BnI0e9 Rafessiom Co*:) The CmVlemra U-
S
lr�\
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construct the project see. ] . sed
cease law does not apply m an owner of property who build, or Improv Iherean, and.
who contracts far such projeaug with a mntmcmt() Ilconsend pursuant in Na Contractors
License lawOm:fiba .B&PCI i
Tkare
C PENSATIO LaRAT10Nnder
penalty of perjury one of Ne following de<laraiona:
n • CeNRmm of Consenuoal(-insert Ise Warkera Compcn-
Scotian 3]00 of Ne labor Cade. for Ne perfonnanc of Nc
work for which this permit u ts,tletl.
rhthiy
❑ 1 have and will maintain Workers Compena0m Insurance, as required by Section
37M of the labor Cade, for the Performance of the work (ar which this permit is issued.
'
My Workers Compensation Internee artier and Policy number are:
Camcr. Poiiry Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissectian Iced ret uncompleted if the pound ts future hurdreddellan ($10))
cr Ins)
I mnify tui In the performance of the work for which this permit Is Coed. I shall not
mplaymy rani my.
".bran4jectn the Wo�rkeri'Cympensatian
L•wsor Cali 0
Applican /s i -
NOTiCE (�5 AP A IL Arta makinj Thu Cci rule of Uchinion, you should
became subject in the Worker's Compenadon provisions of tiro labor Code, you moa
forthwith comply with such provisions "is permit sIW I be deemed mucked.
CONSTRUCTION LENDING AGENCY
-
IherebyamthirilemitItsamnaa.3 lending a.) rartreIcrfarm,rrmor
Ne work for which Nb permit ts knuW (SW. J097, Clv. C.I
Lenders Nano
�nderlAaarea
1 mnify Nn I have mW this application and sets thaI the chow information is
correct. I agree to comply with all city and county ordinances and sum Ina relating to
building consuuclion, and hereby authmim representatives of this city to enter upon the
above-mentioned properly for impaction purposes. -
(We) agree ton", indemnify and keep hornless the City of Cuperlino against
j liabilities. judgments, coni and expenses which may in any way manse against aid City
I. cones. or the totaling of Ni, permit.
• APPLICAX UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
EOGU O S
Re -roofs
Type of Roof
M`
ignAt. cOrApplicanutConumib, ats
HAZARDOUS mATERrALsjpT§CLOSURS
Will do applicant or future Wilding occommstore or handle hauadom material
as &Recd by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Smuts,CodeSmuts, 25532()?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes XNe
If a roof is installed without firs[ obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
it on dao air c'M=iwn a defined by the Bay Aro Air Quality Management
all.new materials for inspection.
District? �a
Dyespl No
,
I have mad the he aNras`mamrhb requirements undcrCMpnrd.95 of Ne Califon
ria Health&Sof ado. Sccuon 25505.25533 wv(25534. 1 understand thmiflhe Wilding
dR9 1 L nl Y M • mom1. that It is mY eelpamibllllY b nadfy tIo aLc pmt f the
mai m tp' s a-GenfRmmofjgn
Signature of Applicant Date
l/
All roof coverings to be Class "B" or better
mhareagcOwncror