01040031 CITY OF CUPERTINO • 'yx, x'. cc,.,x=s n ,•..�,., - "
BUILDING DIVISION PERMIT " CONTRACTOR INFORMATION:
BUILDING A DDRESS { - PERMIT N0.
Rn 171 1
OWNER'S NAMIi: - APPLICATION SUR DATE -
�. LA4ZLA q!
SANITARY NO. ,CONTROL NO.
G O ZO ARCHITEC IENGINHER: BUILDING PERMIT INFO
hidw ELECT PIDMB MECH
. Nzi hI IJ I� I�
,e m - t•,
Z LICENSED CON'TRACTOR'S Up CLARA9'ION '
N I here, affirm that l am licensed nailer s of Chapter 9 hmutnua •Job Description .
yo pm PnAdoe - ,
F:tom with Semina 7(x0)mf Divixion3ofthe ltusines,and Proresei_7 dt c .
q at is in full font, ll L _G`r7 �T rime .
5 O U Lieu, Cleve Lic.K r -
na, 3-p colnemm _ - IVEW•'SEWER -(MAIN).
3° y ARCHI'ECf'S DECLAR N r
Cy a h 1 understand my plans shall be krw as public ecoN.i
"11i� p O Liecn.vc l Pndmeinaal OWNER:BUILU ' - , • '
g try ER DECLARATION
11i1. 1 hereby allnn that 1 am exempt from the Connector's License Law for the
t3G
hollow ingra. (Sestion 71315 IIsines and PraftCm Ayc,y r ,mmy
fF� altich recon,,a permit tconsumc,rin rolve, anadio,al repairy structure .
3� Pr, t t L I the upplicantI h carrol ple.,ilitund,Internal
that he Ip l to the provisions of the Conameni License L (Chapter 9 - Sq. FL Floor Area n
(eo cmg with Samos 71x0)of Do n 3 of the Bmineu vad Pmfe:,ions Cade) -
or tom he a exempt therefrom and the basis for she alleged exemption'Any violation _
of Section 71315 by any applicant fora pamil m1redl the nppllatua to n civil penult
-arnot mamhear Bvehllmleddodan1,(55P0). y -APNNumber' ',"Occupanc "ftU
❑L as owner of propny.or any ennifi o with wages as their sole compensation.. .
will do the work,and the structure is not intended or offered for sale(See.7044. G
H,Ieiolesa
and Pn,r<,aimta Come:Tho Commetnr,License Law does ao,apply ,,an equlred Inspections -
rofino" Who builds d:Improves thereon,Insu
d who arm, ch work himself' `
1 through hi.own emplrywwa.provided that ouch impmveeeats am ant intended or 106 — SEWER— $• WATER
nrrered for.vale.B,however,the building or improvement is sold within one year of .
completion,the owncobuilder will have the burden of proving that he did nm hand or -
npOvfarlmrlN„vofvdv.). 202 — UNDERFLOOR_PL_LIPIB'TNG' .•)
01.as Owner of the pml,eny,am exclusively contracting with licensed mntracnanm 301 — ROUGH PLUMBING
Lonswa she pmjem(Sm.70l Huvro.,,and Polo.smns Crate) he Contractor', ,
localeLawdoasno,aP111b,aaewoa,ofprnpertywho lamd,mimp rovesmereon. 302 — TUB R OR SHOWER
road who sonanels for,mad,pmj«l. with a v analar(O hatted parsmtm to me
Conteemr'a Liceh.va Law- - 502:'— FINAL_ PLUMBING, ENERGY '
01„m nxmnpn order Sec. .B&P C forint,reason _ 506 — GAS TEST
Owner WORKER'S COMPENSATION DECLARATION 507 — F I NAL• PLUMBING
I hereby affirm under penahy of perjury one of the following declarations:. _
❑ I have and will maintain n Cernifcme of Consent to self-insure for Worker s -
Gnnp,a,; an, as,provlded for by Sectinn 3700 of the labor Code, for the
Iafformari ah the and,liar which,his permit is mooed. ,
01 have and will maimm.Worker's Compemmiun Insum os.a,eyuired by Section _
171N1 of,hw Lnhor Ic,for the perliammew lit the work for which this permit is
sunt.My Wnrkc In 'union
Innuencw nnluI y be / -
famee Policy Nn,
CE 'I CA'PIDNOEGXFIRWURKF.RS' '
COMPENSA'T'ION ION INSURANCE E
flits nedinn
need not be completed If Ibe permit is for one hundred dollars -
1$100)orles.) is
1 ecniry mat in IIIc pmformuncc of the wore for which miv permit'u round.I - - -,
,hall nor employ airy per,on is nay earner m as In become Wrvee,m the Worker4 ..
Compemation laws or Culihaeia,Date -
Applicant .. -
NOTCETO APPLICANDE If,atm,nual this Ccnilicae of Exemptlnn,yon should
z henume sukicet to she Worker's Compumatina prnvoav,ofmw Labor Cole,you mus,
Z
0 Ionhwith amply with ouch pawlmnn-a this peen,shell be domed revoMd. -
F” lin CONSTRUCTION LENDING AGENCY J.
a ; 1 hereby aBinn that there is a construction lending agency for the performance -
- eel the work for which This permit o iusO d(See.3099,Civ.C.) - -
G Q Lmok,',Name -
0 z Isnder's Addeo - - -
U 0 Ic n0y0r,Ihave tt di'mosapplication and.nt thathe above inforniatem i.
W (~
coareet.1 agree in couiply with all vity and or ,y ontimance,and state ham,
0 C.1 In building conomajorinad hereby andimeac m,nev,olati,c,al this city or cur,upon '
r� the abavemcntional prapcny her iaspsetion Purposes.
'�. LtiI • pxe) g msaeandm 'fyanJk phut 11 stheCty of Capers no against
lir (Z) liabilitievjudgmenk.coos and exprincs which Tray many way acclne against said
:.7 7� CIIy n' c xnf0 y f g dlhis .
APPLICANT UNDERSTANDS AND WPIC 1PIY
s Gn s Issued by: Dated in)- O
Si ere nl App c . re wmr Dat RC-roofs .
HAZARDOUS MATERIALS DISCLOSURE ,f
Will the npPlisvm lir mere builAing sncupum fora or hunJle hazanlnus lnmedul Type Of Roof ,
av deCnN by the Cu,nino Municip i C,me,Chapier 9,12,and the lleahh and Safety -
Grow,Section 15512(04):'
❑vw. - o No - All roofs shall be inspected prior to any roofing material being installed.
Will meapplic.inormore,noddirgoe<spmnuse eyulpinertordevice, h,rl, If a roof is installed without first obtaining r an inspection, I agree to remove"
emit Immadaus ancormarinanns as defined by the lllry Area Air Quality Management, p g
Dime, all new materials for inspection. Applicant understands and will comply with
LI yet orvn all non-point source regulations.
1 have lead the hamrdo.,imperials teyuirentenu under Chapter 695 of the
California Health&Safety Code,Seaianv25505.25531 and 25534.1 understand the
if the building Jaws not emnsuly have,,tenant m
than in is y resp, i ,unify the - -
occupant nl the tc9uirvinend which n not heare ,r In iia C nillca¢of
Oc<u ancY. _
„• Signature of Applicant Date,
(Owner amhnizedagent, nee All roof coverings be Class
B"or better ,
OFFICE ,