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CITYOFCUPERTINO. , •;`•.f
CONTRACTOR INFORMATION:
.'
HUD,DOva.urvlstoN. PERMIT'
BUILDING ADDRESS'. -
PERMIT NO. '
oO85'
-
OWNER'S"��l11756.' ._
J
APPLICATION SUB [)Ali"
',• ,.
I Z GUIDO 1,. ..
17
SANITARY NO. CONTROL NO.
,SOL
11
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ARCHITECTIENGINLER:'
-
-BOILDING PERMIT INTO '
-BLDG
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ELECT' PLUMB' MrcD
LICENSCDCONTRACrOR S DFCI ARATION
Job Description ' '•'n -
' Ih hY II mlM1 tl 1�fne
..
'IthS 1 n'l000) rD 6 }o' �dt�� '�JfyP le p I . L d it nyI license
/6/h
Litersv
c taamor -G 3
•UPGRADE PANEL ,100 RMP. 'TO 200- AMP, CIRCI
_a
ARCHITEG'r'S DECI.AR PION
"- TIMER ON• OUTDOOR, I_IGHI'S. hIEW 5T. ,UPGRA
I dmd,,dandmyplan ,hmI be,dsad.as pirhim mood. .,
FOUNTAIN' CIRCUITI,IIEXTENSION.�-FOR FOUNTAI
OWNER BUILDER DECLARATION
I h by ff 1M1 t I an mardrin fmai the Contractor's License Law for the
fol g' (Sect(Secti 17031,5,Built...d Peadfisian, Code: Anycity I,, only
tll d I 'n,amebicwb h quP It :1
• .. s
PriorIn t.t.requires1happlicantf suchpermitt flsigned:Itemenl
.SgkFt. T"IOOr Area
ValDahon.
that he licensed ptt (he ronswams oftM1 C t' t License 1(Chapter9-
(commencingwlb Section 7000)ofDivision 3 of the Business unit Profession, Code)
or thinone is exempt IM1amfarm and he b .. to the alleged mpfnn Anyvlmmu n
of Section 9031.5 by any applicant let a permit snued, the applienm In a civil penalty
'
APN Number �
� Occupancy Type
of not room than rive hundred dollar., ($50") ,
property, r v employees s pcns7
-tilowner ohne rt n with wages a. -d i. le com tion:
_ r
i "Required Inspections' )
will i tl k d thestructure t intended r offered f r 11 '(S ]044
'Ra 1r . proper reds ccs rn c 1 : 1 1 : n I apply to an'
own property '' p- II rumnnA h d .. t kti mall
er ufo his own provided 1hm such t n eat is I e net ',b Jed of
employees
fered fon sole. the building en improvement , smold Primed ,be year of
0�boftr
356 ]. ZG4S. RJG
w er rudder l
the owner -binder will have the burden of proving shin he diJ nm'huilA nr
•. s
hiompletifar
p f purpose fame)•
,, .'
❑I as raster of hip properly am exclusively contracting withlicensed coulactin s 1
304 --" ROUGH ELECTRICAL
construct theproject (Sec 9044 Business d P od ss ons Code:) The Contractor's
notapplyloanowner fn improves themonn
50;f: — FI'NRI_ ELECTRICAL ENERGY'
Lieadi-a does p Iywhohald: r
anti h I ill, f such projects with contractors) r d pursumtl to the
- — FINAL,
�"-505
e, t hm Lied dLw.f -
.. _EI_ECTRICAL
_° l In, exempt underSu. ;.B&PC in thixmi,en
owner nam
WORKER'S COMPENSATION DECLARATIONf Is
-
..
I herebyaffirin underpenally or pep > or [lie following d I t s
I hard and 'll dancond . Certificate ofConsent t If' 'lfoa, W ker-s
•.10
Compensation, as provided r by Sect 39011 of the Labor Code, for the
Is-
'Nal"Invarive ofti work for hthis permit is issued,
'eYih Jwll me ma W kers Co p f nlnsuran y reJ by S' fan
• ,
�j071 fth Lb rCJ I d pito. fin wnkf- h hlh p ,nl i,
iss d MyW �-rc � In��w' anJ P,I ) mM1er.ru
,
�Jff�� 1
cvmcr', MY N . ^DU• L
„• - - r
_I'^i1V,
WORKERS'
CERTIFICACOMPENSION OF ATIO
+ t
` COMPENSATION INSURANCE ' -
INSURION ANCE
•- •
0 his weron need not be mmplemd TIM1e perm r is for one ht ndred doll rs
e 4 - .a S
($100) or less.)
1 certify that n the perbx mance f II k f which thisp it i, nemed I
_ -
,?tell ear employ any person in any seas tobecome subject to the Workers''
*
darner
Compensation Laws or California. Dam.
,
r ,
Applicant
it •'a-.
- -
NOTICE TO APPLICANT. If, f1 A 61h: Critifisereal Exempriml you shot lit
becamesuh,cut r.lhe Workers Compensation Poi sof the Labor Cede, ycunant
!milm, It comply with such........ as or this pmeni(shallbe damned invoked., I
CONSTRUCTIONL ENDING AC HNCY'-
1 hereby affirm that there is a contractie t lending agency the the performance
,
ofth Isf,rwhichthis permit is l...W(Ser 310] Civ C,)
Lend r. Name
_
_ 1 ..
Leddcr'. Adeffe, -
♦ _ '}.
1 certify that I h d this ppb I nsimulate the, lM1 ab 1 a I,
t t I ting
curate,. 1 g t .IY tl II and moan an I since
ly reminders
tbuilding consmeti t and hereby doth epresenloli w orlhts,ty mcnhrtma,
a
the ab.,wendationed.rope ry f r InsipidEt n p rp ce -
- - I:' ' .
- •-
(Y)eBeatcdmdmfy andkeep h : the Coy of Corsi .,ain't
•r s
liabilities,judgments, costs aad wm,me which may In any way mune agar laid
n
��
City in nsequece ofth gaining (if lh pcmil: -
APPLICANT UNOERSTA�'D�A ILL COMPLY WITH ALL NON- INT
[saDedb Date
Y'
SOURCP REGULATION7.L.-^ 9 p
•
�'
Signature fApplearticVVVVnrJJJJt al
Re roofs
.F
_ HAZARDOUS MAT IAI S DISCLOSURE'
Willth apps' r f t b ld' g p to ,h dl hoed" . .lateral
TYPe Of'ROOf -In
-
as Jefred by [he Criterion Municipal Code Chapter 9 l_, nd the Health and Safely
- +
Cede, Section 25532(a)', _ /•
'' ' ' ' 1
❑vea r
„ '
• All roofs shall be inspected prior to any roofing material tieing installed.
Will the dP.licart or from hirudins eaerient' irse equipment or devices which
If a roof is installed' without first obtaining an inspection, I agree to remove .
coil it cot nl, as da6ndby the By Am, Air Qumty Management
-r' rote air"- � '
;
all new materials for inspecti•ollE nt Applicaunderstands and will comply with
. ,.
all non -point source regulations.
1 h d he harould.on'smarmal, y tau do Chapter fi y5 the
a -
Cvrf Health Safety tl Sections 25505,25533and 25534 I nit nd(ar
--
-
fifth trilling d s not e rl [bar it myresponsibilitys n 'lh
p t Id qthichmidbeme,pror issuance r
,.
Oc p y �m
Signature of Applicant'Date' I
o
All roof coverings to be Class B or better:
Owner tirautharizd nt I Date
OFFICE
,.,_ _
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