04120146CITY OF CUPERTINO
PERMIT
CONTRACTOR INFORMATION.
BUILDING DIVISION
BUILDING ADDRESS:
CORTE DE, S171111117
PERMIT NO04120146 4120146
_1Q421
OWNER'S NAME:
-
PERMITLSSURDATE
SYLVIA GAL
NE:
SANITARY OL 10.
ARCHITEC (ENGINEER: -
BUILDING PERMIT INFO
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LICENSED CONTRACTOR'S DECLARATION -
A ION 9 (cmmmcncing
I hereby affirm Nal 1 am homed under S DECLARATION
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Job DOSCrIpUOF I)Js� q /qk f' E.®
_ VViQ�U\�p�y
width Samoan 7") of Division 3 of the Business orb Profession Code, and my liccvc is
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ren Tame anderrat.
ELECT PANEL UPGRADE (200AMP)
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Linn. Class Lic. p
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Dox Ommoleter
ARCHITECTS DECLARATION
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I undcrsunJ my plans shall be used u public rtnrN
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Licensed oval
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OWNER -BUILDER DECLARATION
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BUILDING
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Wreb,Profes
I hreaso affirm 1 LicenseLaw For NC
eacmpt from the Conine
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Co : Any sty nr county
on 1. yc
r01.5. Business and prome,
muno. permit
followhich
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do .I h. or:
an.m.
which myuires a Permit m cnnsuucl. ale4 improve, dcmoliah, or repair any atrwwm
to to
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poor to its Issuance. also requires the applicant for such Permit to file a Signed alalemeal
Contractarsucen.LAw(Chapter v
Sq. Ft.
Valua[io -
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that he isliicensedpursuamlcthcPmviaiansorthe
(commencing with Section 7")of Division 3 of the Business and Professions Code) or
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3 $
that he u exempt therefrom and Ile basis for the alleged eumpdon. Any violation of
3 7AFMMWter00
- Occupancy Type
Section 9031.5 by any applicant for a permit subjects the applicant m a Civil penalty 9f
not mom Nen five hundred dollars ($500).
0 1, AS owner of the property, or my employcm with wages u their sole compensstion,
Required Inspections
will do the work and the structure is not intended or offamd for sale (Sec. 7014, Business
And Profession Code: The Committees,�.. - Law does LtLadors not apply Nowner Of owneof
property who builds or i m pmvss the eon, and who doessuch work hirrulf or through his
own employees, provided that such improvements Am not intended oroQered for sale. If.
however, the building or improvement is sold within one year of completion. the owner.
b Id 11 have the human or proving that he did not Wild or improve for purpose of
owner of the property, Am exclusively contracting with licensed conmecxrs x
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co ,be project (sec. 7044. Business and Professions Code:) The Committers Li-
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cene don not apply IA ao owner of property who builds or improve thereon, end
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wh9 nmacls for Auto Pro aswit a contractors) Licensed pursuant to the Convectors
ICaw.
lam Ampt On . B hhfP C for Nis men
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Ow IDafC// � �
WO O TIO EC AL� N
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1 he AfR r pe t perjury one de following dcd.lion:
I have and will maintain a Cenificax of Consent to ul6insure for Workers Compere
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sation, u I mvided for by Section 3700 of me labor Code, far the performance of the
work far which this permit is issued.
0 1 have and will maintain Worker& Compensation Wmrarox, As 2qulmd by Section
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moo of the labor code. for the performance of the work for which this Permit is issued.
My Worker's Compensation Insurance carrier end Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
To. union need not x completed if the permit is fomite hundred doilars (9100)
or Its,.)
rm of t c work for which this Perron u issued. I shall not
1 certiawfw
emplman cr b' o the Workers' Compensation
Lawsx
Appl
NOTfm no al em o u
become suhja IM Y r r' penssli n pmvisio o Je Tabor C de, You muss
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fmnbwith comp itAs isin Orth permit silt Ib domed revoked.
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CONSTRURION LENDING AG Y
I hereby affirm that there is a conuuction lending agency lot the performance of
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the work for which this permit is issued (Sec. 3097, Civ. C.)
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Lenders Name
Lenders Address
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I certify that I have red this application and sax that the strove informationis
rises and state relating m
caned, l ansa x comply with all city and county c ng
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hominy auNonacreoses. iw of Nis city reenter upon the
mad
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abovengcotioned property fo
above cd
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dmouninion Idol, hs.
(We) agree Ice save, indemnify and kith harmless thew City ofCupertinoagainst
(We) a to save
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against
liabilities. judgments, costs and expenses which may in anyway accrue against Raid City
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iAIPLICAP ce of Ne RSTA of this D�IL OMPLY WITTI ALL NON -PC
Issued by: Date
SOU E ATIO
Re -roofs
_ 1. Date
g re of c RDOU MATERIALS CLOSURE
Type of Roof
I appeamo turn uilding uecupannom or handle hv4rduus mammal
u dtfim d by On Cupertino Muni 1 Code. Chapter 9.11, and the Health and Safety
code, Sectmn 25533(-)+
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will thea applicant or future building Occupant sae equipment or devices whim
Pp ga ham
Emil harardnus air conxminants u JchncJ by the Bay Arca Air Quality Management
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all new materials for inspection.
District' /
❑YcA gVT!(
I have mad Je harardnus materials ne ineam. under Chapter 6.95of the Califon
,
nix Health�SdayCo&dm 'un�11,dy1uodcmmddwAff,hcWHdmg
l am n thdm ntiry the acupant ^ Nc
is oat m 1pn ofgg�up
Signature of Applicant Date
All roof coverings to be Class 'B" or better
Owner or ag—! Dam