01010057 CITY OF CUPERTINO- -
BUILDING DIVISION PERMIT "CONTRACTOR INFORMATION:-
, BUILDING ADDRESS ` _ .. to PERMIT NO,
1779 COLLINGSWbRIH ST BOB G
MASONRY IZ110i.0057
OWNER'S NAME;: - ' APPLICATION SOB DATE
S ES `DR'
nf�
PHONE: - - - SANITARY NO,', CONTROL NO.
.t.
14. — C
G aZII
ARCH'EC'I'IENGINEER', - • - - BUILDING.PERMIT INFO
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E T PLUMB MF.CH
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, RLDC ' -ELECT
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X S m Z LICENSED CONTRACTOR'S DECLARATION - Job DCSCrIphOn' _
the b) ff- mt1 need I par fi I'Chpt J( mB ing
imS el 91H111) fD' 7 foe Hu dP ..' t.Cd Iny lie
a � is I ie ha
ad rre t_ a CHIMNEY REPAIR
�q5 Oe O Doe - Contraction
C5�
W3700 ARCHITECT'S DLCLARAFION se I do .1 J y plats,roball be pud it,public record,
�+Wty>f
ulEapO
Licensed fn4:i nl
OWNER-BUILDER DECLARATION '
vl I hereby affirm on 1 ani exempt from the Comme,Ctr License Law for ma_ -
E-,Z�E 'chi n5nives a(Semon]nBLS,Basin,,,and er;dmlons Cada Any city ar ttmmy ` e "•_
S O ,in
y F 'I I :I t p J I'h p Y someone
atement -
e Pro : e I .dapplicantl nne r, fl b d.t statement
w 3� math m II p d p ' flh Connector,i License L' (Chapter9 y Sq. Fit: I''lOOr Area . - - , Valuation
-(wlenba rgw mSmcwta;0n)d The basis
oresleei mpsnlJair.Annru Cnde) , _ . .
ormm ban exempt Ihcwlrom and IM1e spars for the alleged e.entptiole Any violmirn - +�
of 5ecdon 9031.5 by any applicant for p permit dhle<m the xpPlicxm lop civil pwldlq
of not more than livp hundred dollars($50)1 - i. APN Number Occupancy Type- '
•❑I,ue owner of the pmpeny,or my employe es with wagas as lheire ouraparealiom
will do hi work,uad Ise saaewrc is sol immnded or offered for sale(Sea'70,f4. ..
Business sad Eroticism,CodTrip Contractor's License Law doesIapply t 1. "< _ Required Inspections d
mone,offormerly Whbuilds provas human and who due,such workl ed
nm soh" mall,p ddmit: 1 ' ( t. ' ,in d I sae , 10'1 — FOUNDATION ,
offeredf ! If,h tl bolding p t' II 'lh teye f
completion,me twmrncddnrwill have do n rde,nfla m6 that he did not ball or, x _ - 312 — CHIMNEY REBAR fl• STRAPS
nns
°I1 wmuoohed pny,,mexew velronmctmd_wair fica;,edcompactors to � ' .:r '' 514 FINAL PUBLIC WORKS ,.,
construct tiro project Bee 7044.Business and Professions Coded The Commemr,
License Law deep not apply to an awneror property who builds or improves Ihaicon,
and ls n
who contracts for num'projecwith a,onacmgs)licensed'pursuant to the t
Cnmrac(cr's License Law. - v. ,
s°I car uncippaunderSeeB&PCto,this _ - - i
Owner - Dal . .
WORKER'S COMPENSATION DECLARATION - _'.
t
-1 hereby aft rot t oder penally oI pe jjy me m the fullow ng Jed r t on:
0 1 have and ,It maintain a Comorl,ale if Conscon nulf-miare,for W k : ` I
Compensation, provided by Section 3700am m Labor C d f thef� -
v
perfiammove
of krwhichm' permit d -
°Ih (will mountainW bar's Comp t IrequiredbySctin,
3900 of the I bur Code f r be purbarmanner of he weak fo wh ch this per i I
issued.MyW kcrsC pe:m' nlrntrt a curter and Policy number are
Carrion": Policy No.:
CERT IPICATION OF EXEMPTION FROM WORKERS; '
COMPENSATION INSURANCE
(This semen need noI be unnplant if the pion is for one hundred dollars
-fS100)(This
I comity that In de performance of the work for which this permit Is issued,1
shall not employ any person in any manner so as to become schjecl to the Workers' -
Cnmpensatinn Laws of Califorms.[)ale ,�• -
" Applicant 6'
_ , l
NOTICE TO APPLICANT.If n nmki b d C 'i fca e of I,xe mpi on yen d I - '
• Z Imo na subject m the Worker's Compensation provisions afro Labor Code, "a
xl fe ' r
Q Q fnmbwmeonpl)verb ti -ie
p onx,rlh sperm tsbdl bed d eked - - '
CONSTRUCTION LFNDINC AGENCY - .•'t
1 hereby offr n that there a i lending aperay'for the'perfur inn e
of the work for which Iht punuI is issued(See 3097,Cm.C)
�
t (� Lend Na nn
r�''O Lend 'Add s
[certify that In [this appliciplardard. t that the h into i is
I:, F correct.l agree to ply with. II city and courty ormrpacind state laws relating'
(ch Id' gc,ndun and thereby o reby andu tmpfescmatvc, fd ,city(center upon - ,• -
�. the h .t. cal Isp yy I in im,,werim.parptai
Q,t (W 7 am tindemnifyand k ph I i:1heCity fC Penn beo t 4 _
y limbi 1 Ib n m.- lsnnd p h h I y i b y way creme.apalinst,sad
C„) City'in consequence of the Staining of this prompt.
gPPLICANTUNDERSTANDSANDWILLCOMPLYWITHALLNONPOINT- Issued by: .Date
SOURCE REGULATIONS. Y '
Supn(Apphcanucamrucmr - Dn�te' Re-roofsis -
HAZARDOUS MATERIALS DISCLOSURE
Willme apples t mi hatimbe hi f 6 "pn t t ..handle premium mnradal Type of Roof
as def sed by the C puri Municipal Code,Chapter 9.12.and tiro action ad Safety _
Code Section 25512(x)'
°Ys o Nn `' .. All roofs shall be'inspected prior'to any,rof fing'material being installed.
'VIII the uTpliccutorr nome b iIdtg occupant useequipment or J hath ;If a roof is installed without first obtaining an inspectioh"I agree to remove- a
hath d lam m. s dermedbythe'ByAreA Qua]t'Manhemim '
. uta t all new materials'for inspection. Applicant understands and will comply with
El Yet ON. w .all noh-point source regulations.:
I ha,6 accol theloo,andims materials automated,order Chapter 6,45 of the -• - ,
CrIfforriaH lth&Safety Code So,mcm,255n525533 and 25534.1 madep,landtha ,,:
if the ho ld ng does not cwreptly have a tenant thus my responsibility firmly the
occupant of the require pens which-must be t pe m ass a ofa Cernl caw nf, -
Occtpamy. r - - .t _
'Signature of Applicant ,Date
0„nora,nalur ¢edagent; t Date ,.f - �'All`roof coverings tli'beClass`B"orbetter
of
OFFICE
CITY OF CUPERTINO "
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BI111DINGAOORESS: \ �. _ liER"I'[NNO L,
/_ O
OWNER'S NAME: APPLICATION SUB DATE
PHONE: - � SANITARY NO." CON'IROI.NO. "
r
O ARCf11TECT/ENGINEER: BUILDING FERMI"r INFO.
w C -DG ELIiC'IPLUMB, MECII
0 O1 LICENSED CONTRACTOR'S DECLARATION Job DesCn OD
I thereby...inu Ih 11 a IiccnecJ d p re of Chapmr 9(sommrncing / .
FvJ A. wthS t ]..r I'D )tithe In JI IceaonsCn rylmuse
is m II I' a
3 LL N nal o f
ARCl111'IiCT'S D
acrd a „y plan.+Ban he axed ae R,reeom746"9 O
ip O LicmieJ I'rnfesxinnnl
OWNCR Illlll DER DFCI ARATION �/ll��
att1 hereby affirm that I am exempt from the Contractor's f La for Ole
t G a fall Ing m..n (Salton 1031 5 Husinal,amt perorations CW Any lily orIn, -
$ G
whichrt4" permit I construct, n p demolish, p Ysonatare _ .•,
ER dF pr. I I .. I 4 Ih III' tf Ip,mu 11 g I.t le tam
hat ?a fill.ledp l to lh1 fm c t" t Literot,La,,(Cl.p,,9 Sq. FL Floor Area Valuation
(cont rte rem,with Section 71X10)of])it num 3 of the Bax mess mJ I rof+mfons Code)
or that he is exempt Ihcrefron and the basis fnr the alleged exemption.Any vnotation
oSection]031.5 by any applicant for v pctmil sal Jccts the applicant In a civil penally
of not n,am than its,nnnamd danars($sw). - /SSL AP%?umbe� �a Occupancy Type
j ? �
❑I,downer of the anti
they,or my e is o t needed wide wnyex a amir Bole a(S enxT", .
will ne the work,amt the nmcmrc 4..v Bol r',I. or offered Iia ma Apel.],,An Required Inspections
AwaBusre
and Proproperty
W 4.o b Code:The Cortowe,1hor'x License m do Jt such
now apply m alf ..
awoer of h his oA em builds or improves thereon,and who does such work himself _
or roll for
Bis own however,(] poinded Ihul such improv is ems all not one near or -
...bred Ila rule.IL however,the hnildi ti or improvement is sold within one year of
nmplwian,the ewne,I alx a will nave the bnnlen al pawing Ilan ho tlid not buildor .
improve for purlxne of sole.). I
°I,as Aware of the pmpeny am exelu.+ively contracting with licensed contractors m
construct the project(See.7044.Business and Professions Cotle.)The Centralia',
Li an.Law does not apply to an owner of property who sold,ar Intpmves there r,
Tnd who umtmc, RA such pr)ecu with a cnatmmwr(s),Ilccnsua purmvnl w the -
Commcea'.+Limn+eLaw. -�
❑lam exnnpt under Stt. ,B&1'Cfar Wis rcaum /
Ower Date D , ;-
WORKER'S COMPENSATION DECLARATION �
I hereby affirm mailer penalty of perjury.nc of the following declarations. 612000 1
JAN 1
O 1 hal and will maintain a certificate of Consent to self-imma for Workers - le
Compa�nc 4.o s video for by Section J]IXI of 0c Utbor Code. for ,hc /
JAN 1 G 2000
prfnn nw of the work for which a,iv permit ix ivxuoA,
All And "II maintain Worker's Co,pe t t 1 ,mane 1 d by Section I -
1X1 f the Labor Calc for The R'Bmnnnce of thework f which this perm,(is
{m J My W k s Cam .sat mer n I" n be
Car 7 040 �
CBRfI lCAr10N OpI:XI:MPIION PROM WORK — - - - --
COMPENSATION INS 014ANCE
' (This on.need now Ix eampletnl if the permit is for one hundred dollars
1 certify Ihat in the performmucc of the work Iia which Ihiv,cont(Is is7uad,I
shall not employ any person in any manner so vs to became vobject to the Wacker
Compcmmion Lw'.v of Califamia.Dale '
Applicata ,
NOTICE 10 APPLICANT.It, it,,making this Collocate of Exemption;you should '
become hire, the W..sees Compmuta mr,kions of the Labor Cade,you amo
Q O sm um
forthwith comply will,such pmvivians ar Jsha
tix permit ll he remold revoked.
v
F > CONSere is.
LENDaii AGENCY I/
I hereby which that mere t is construction00)7,Icahn,agency fnr the perfatmance (meq/{{/v 77,
�
W ,�. ,of the work fnr which this .it is issued(5ec.31N)],Civ.C.1
Lcnder'x Name /
Z Lender's Address
I. .
I cdrtify that lhme and allcit and
ounty OarethauhctMwc imawsmion is
[..
correct.I cone to comply with all city and county aNative%odna nate laws enter
run
U the al(Jingctmstmetinmi and bymathonaptuposemmives of this chymenmr uptm .. -
Q. .the b f I property, de n:per t '
Q.Z) (W) 6 I J p ilk PIP" .the A.,Aty ICI n g lel
rO .bah I'I 1 Jgt t d. t t d P :. h'ch n ry m any Y' ms agams, ,d
V z City t me APPLICANIT UNDERSTANDS
Rth NDSA of this WILL
- //� /x-00
SOURCE REGULATIONS. Issued
AND WILL COMPLY WITN AILNON:POIflf Issued by: V Date
Signutura of AppllcuntlConneclor Data - 1
Rc-roofs
HAZARDOUS MATERIALS itDISCLOSURE
wenythe Chcamtr(Etta hulId'
m pant mtrcnrhandlenddr hwmdous Safe,, Type of Roof
ax de,Section
by the Capaaine M ,Je,Chapmr 9.13.dna the Health And Snfay c
Cale,ti ye, 35532(.)!
°Ye - mil No
All roofs shall be inspected prior to any rooting material being installed. .
Will the applicant orot a b don,occapAna.,a ataijurena o1devimuwbiob If a roof is installed without first obtaining an inspection, I agree to remove
emit hartrcom.air contaminants efined by the Bay Area Air Quality Management
-• Dixtriere all new materials for inspection. Applicant understands and will comply with
°Ycx °' ' all non-point source regulations.
I hall read the hue' does mntedale regwmmmnhs under Chapter 695 it Ihn
Camamin Health.@ Sn&t erste,Sections 35515,355 it 25534.I atiderstana that
ifthe 'IJing does note ally base'v,enanCtha st msponsihility ton ify the ,tom
Pam t the gnimt cats which must a prior to issvnncc of v Cc real
an
. .Signature of Applicant to
o e m let nant Lao, r All roof coverings to be Class "B" or better
OFFICES