00100197 : CITY OF CUPERTINO Ig.,nt
uou,DING DIVISION {PERMIT 'CONTRACTOR IINFORMAT-r1 >-
'BCILDING ADDRESS: ' PERMIT NO.
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OVIIM
,OWMBLJS Ay
NER sfT'haCal r `LJ APPLICATIONSUBDAIF
7
LONE. — LEY r - SANITARY NO, - CONTROL NOis
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O O V RCI B"'TIHNGINLLR • BUILDING PF:RMI'1'INFO -
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s L ELECT 'S.IPLUMB MECH
6F1 LICENSED CONTRACTOR'S DECLARATION,
.z a I nemb rhrn,allot am Iinelt�d miner Y' rend t' r g - .- Job Deseri tion - - - '
o z o r p r (nn,menrn P
ma
C 5-w withS I 7000) fD a Irish,N a
�zC¢ an
Liver"
ic is fIl al�l:x dI L - I # ais
3 sc r °°I yZka u c , u ,
as dent d Ak1°TLCTSDECLARAT°" REF'IFE WATER HEATER' & WATER SER'JYC6
ypl .ehull be usentts Pohl metals r -
reW S p 0
Licensed Pon,sfobill c
°i OWNER-BUILDER DECLARATIONr'J
I hemb,ofrrn halt Iexcerpt from the Contractor,License lau far the t
Z C foil g .� I e i 71Y11 5 p ' d 1 f Code: y 'ty oure -
s❑ wh q — p tl I t n �p d Ish repair Y.t structure
' 3, °Prue t 1. rcgli ep ifou tl hp is L dt metl . ' - r. ,• .
(a licensed :amt m p .Of Continuum,1 ro (Chapterode) S Ft:Floor Area - - Valuation -
(wIntoningwithBec n70W)'dfD vis.. iot the he
nine and infAn vi laden • ' q'
Ise t e pt II G and theh.t f ialleged,thesacroiliac.A iv civil olmion c .
Ofn i eIt ra nY'pPl ' If p 1' 11 IS lhu apPl 11 ' pe miry 'x
mr n , re n,.,1 cg n w d hdmm resod) a - _ APN Number , - - Occucr pe
-01 s w rnfinepropeny army employ with wages ase Y le compensation, '
B d Ili k i 11 o , 'burned If d 1 .al (S 7044, -
own Ie r Code The c e :r L does l z'rkhimb, ' gg quiredInspections -
r of propertyWhoe l ee r hnpmro nth a am wendoes sc not int himself or ;SEre^@4X107. �iu�
owner
for
own employees. building
do[eachimprovementsis suls are nen intended or - - '
offered tar Sala.v however the building or unprovenremt n sold within rime year or
mnpmdoor me owner-buddal'win naso the burden nr pmvmg mm lin did.,ol Hood m .
in,pra�e for pnrpn.apr ade.).� � � _ p5q0'?_ - GAS
PLUMBING ,F_NERGY .s . -
ml rill Property,e41trexclusively I t sns Craft)
r O. d IPfln `v 1.rLr 6. ,DHS TE_5T `�/I
ml ul p { t(Sc ID44 H : IP [ Cd )ThC taints $ ' r
Le L e 1 apply(()no fp Pel} I builds phereon, ' - 507 FINAL- PLUMBING - 'I'.
anal h contracts f h projects w th I ctons) licensed p n l the
Cnm 'I' Lt .. - '-
❑1' pt utderS - ,B&PCI thtsre ' •, - o' - Y/� +�
Owner Data s2 1 WORKER'S COMPENSAI DON DECLARATION, ' - - v. , ,,
I farcby uRrn under parody of perjury one Of the lbllpwing de of - ° _ �•
� Ih d will and Certificate TConsent n, If' feeWeakery
of is i n as provided l sy Section 3700 or the nor Code, for the
-rfarmi ofthwork l which th'permit :issued. ' -
.DIh - d call cut Worker's Cprements.harmonic,a,waltialbySwuon -
3700 of the Labor Code,for the performance of the work for which this perm I is
uerudMyWrk'rsC' transition Insall ce carter and Policy n nmc
bar '
Car' �6 Policy No 7 T l
CF,RTIFILAI ION F EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This wona.need nor be'coundetul d the permit is for one hundred dollars -
0100)In Lads.)
I county that in ie performance of the work for%Inch(his permil is issued,1 r _
shall net employ any person in any manner so as m become.mbject to the Workers' - - -
Compensation LawsofCold..nis.Data
F r 5+ -
Applcant .
NOfICETOAPPLICANP 11i offer making tho Cendficate of Exempfot you should -
z luny subject t e e Work...C p ar f IM1 Lah Code you nml ` r -
0 � fonnll comply with suchprovisions or prat droll he deconal rcyOkcd.
`4.I CONSTRUCTION LENDING AGENCY,� I lberalwaffind that thsa m nn lendng,gen y fertile porfnrmunea _ s - -
❑ ;Lent Nauruwork t {ieh i pet'm t is ssed(See 3097.Cis.C) r
z cem rs Aarnew4 c ,
I
Ibis
to
J -III I aJ ' thin 'hinformation's
concert. dee ocomply e all d county . state I reIsi,g
thaikdlr8cadmnandrefeby
achraroenTroselnncvnnhinalymemerapnn
the,n m t lenyfori } 1 I rp:.
pl rW) bre tos inderaphyandk ph ':
.' .
the City ac p I goon
.N VJ City i l,cme elfveto, d Imdhi her may al en) eY a wga against and
C.7 z APWICAT elflM1 NDSA AND
perm em° .
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NUNPOINT
SOURCE REGULATIONS, I _ Issued byDate ld /V#'/ V^
Signature ofpppncard/Cradar - Onte Re-roofs - -
HAPAItDOUS MATERIALS DISCLOSURE - '
Will hom a,,Ii,aIt f t h-larg 'ata 1 aaaLe naaomlmtn „aerial 'Type of Roof - YIs
Code,
San by the Cuparl m Mu i e pal Cade,Craplxi 9.l2 o,d lhq Heahh ane safely Imo . -
°Y 1 . All roofs shall be inspected prior to any roofing material being installed.
W Il lh 'PPL'- I ' b'Iiny p ' . exportation devices 1rah If a.roof is,installed without first obtainingan ins ection, I agree to remove. `
cmitl zard lura. II instalment by th B.,A •aA QuadIy Managenenl - ,P �'
is
all new materials for inspection. Applicant understands and"will coin I with
❑Yad 'o No '' all non-point source reguPlations. '• pp' - ' P Y •
1 forcemad
be
h aryl materials yiu e t e Chapter 6.95 of the ' � � '
Aha - 11 nh s , [ty i de t 25505 It it d 45534 I d Ia d Ill
ti Ianan 'Ir-1 does t umnny havea re, Ila I't . y :p nrryl Iry lne
occupy rem r cots wh'IT oust b w Pr'or ro udu' ce of 1 Csmhwte Or
omanal �� I -
i
'- Signature of Applicant ,4 - Date " I:
').nor m tried agent Date • All roof•coverings to be Class'B"'or'better
'
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OFFICE