01060001 CITY OF CUPERTINO - 77 t'r` -
BUU.utNG otvtstGN PERMIT CONTRACTOR INFORMATION:
BUILDINGADDRESS: - PERM]]'NO
o 'Se Win/ 7' 0 c:.✓ �
OWNIiR'S NAMIi: APPLICATION Oil DArH ,
01V Al/ S
PHONE: SANITARY NO. CONTROL NO.
CWo ARCHITECDENGINHIA: - - IiU1LUiFG PERMIT INTO �•
u _ - hu ELECT PLUM MECH
a
z$y I hereby arLICENSED amlienseee�a rpR S DECLARATION r9(commencinglob Description
provisions o per
vl�y with Semina'l1and of Divisian]ofthe❑nsiness unJ Mnmsslnns Cale,and nq liecnx
Is in mu rmN Imll'CR0.'L
O�u License Clens ' Lic.tr
3 F Dam
�
ARCH S DECLARATION0 1 1 t nil my ' :shell he Lived.,public records 4/ /
O
�p0
QWNER Lc eJP f ' Dont
q y BUILDER DECLARATION
1 hereby so (See that 1 exempt f Ib C niter r. License l'o for the
CLQ follow b .(Se l l )ID I S p alt . uo f thumb C 1 'Any cnno,,aanty -
S O tail h 4, perm t :I nil 1 nal 1 p slmment .�
'h t t ep r y .provisions
I f n parent ic signed(Chapter
Chaps em
'hat licensedwith Section
e tt m p v+m. ren t Contractors 1 Law cnsCod9 Sq. FL Floor Area Valuation
(cthathe k esem t therefrom
7")at Di basis ort ea Huside exemss andption.
Professions Cods)
or that he is cecmpt therefrom nnA me basis for rile alleged excmptinn.Any violation '
nl'Sectinn]11115 any npmllenm lien:punnh'a jugs the... ...um u+u civil penally
t rnm ma lilt, t nawrea amlaa�ssllul. � APN Number 'Occupancy-Type
(yYl:ns n ¢propeny.mmy employees with wageswlhci,,oIe compensuunn,
well do the work,unJ the ntmcturc Ix nm Md or offered for sale(Sea 7043,
lhusmeis sued Praia...an,Cnde:'rhe Convertors Uean,a Law does an empty .no ' Required Inspections ,
rof prolwny Wha builds nr intpnwes
lhercon.and who Jocs such work unwell - -
or Ihr6ugh his awn employees,provided that such improvement,are on intended or
offered for sale.If, the building nr improvement Bald within one year of
r .
c 0 er hnailila Willu1sc the hardell Of Proving that h 11 anbuild or
topo"e Inm ' 1l ) ,
01 me .,.he P ecny Iacontractingiwith I'c xdc t taunt -answeril p ,0...jeo ]111d u, and Professions h n. Cd,itap Connector's -
.a L w l t Pct ' I P Pty b hl dJ p thereon t /
unJ who sna abs f r nth projects with a rat usl+rfs) tsaf pt rxwtl m the
01 am excl Lieenx i4
W.
i ❑I am exetnm anile .�. 110
Pc mi. manOwner!/ // I]No {AX� 11 KHRGTLCLARP • - <
I hi affirm under penalty of wqw,one of the following declarations:
El 1 have und'will unuialuin a CurliEcave alCoaleal a lel-in, Worker's ,
Cour,cr lin 1, ac provided far by Seam. 3700 of the labor Code, for the
performance ofthe work for which this permit is i...ed.
❑1 have mal will maintain Worker's Compenvation Insurance,as required by Section
3700 of In,Labor Cale,r t'me Iwrb....eawe Lar the wont:rnr which mix Foran Is
issued,My Workers Compensation lnwrunce carrier and Polley number oro:
Cartier: - - Policy No.:
CERTIFICATION OF E%EMITHON FROM WORKERS'
COMPHNSA9'ION INSURANCE .•
Mus sermon need not be campleted if the Permit is for one hundred dollars
($100)ar less) - _ -
I nailythat in tla performance blit.w...k for which this permit Is issued,I
shall not employ any puna.in any nwnner on as a become tAnce,o me Workers' -
Compensation Lowen'California.Dam _
•Applicant
` NOUCCTO APPLICANT':IC aftertnakingthls Cenifimmot'Cxcmptian,you should
became snhice,to the Winker,Compenof sation provisions the Labor Cnde,you must
Q I'anhwitb cohlgl with such provisions or this pedant shall M deemed revoked. J
CONSTRUCTION LENDING AGENCY -
� 1 herby alarm that mere is a eamtmaion mndiag agency halite perfprmanee
of the walk or which this permit Is Issued(Sec.1197,Civ.C.) ` t
S Q Lender's Name
z Lender's Address
V 0 I.coil,that l huvc read this nppliewian and state that Iheohave information is
Ors F collect.1 agree ,, ,ac,I,with all clly and county ordwancav and slate laws relating -
�l to building construction,and hereby authorize representatives of this city to enter upon
Wthe above-ntemionee pr +carr impcmion purrysus.
tiq (We)agce to undk �h less the City Of Cultivation agmnnt -
fn Ball 1, dgntm I c : 1 nm h I iy In any "y a against s,A,
C,7 z
City c n 4 en trtl g t k+l lh: 't
LICANTO ER ST\ND AND COMPLY WITH ALL IN )I'
Gu1ecE Rrr L TI .r�v/ Issued by: Date
Signa r 1 nuc. mac nate Re-roofs
IIAZAR US NATE DISCLOSURE
win mehvphamaar tarenaudingocco,nmcase Orhandle haenmusminimal Type of Roof
as defined by the&,taboo Municipal Cade,Chapter 9.12,and the Health and Safety
Cnde.Section 2553200'1
❑Yea o Na - All roofs shall be inspected prior to any roofing material being installed
Will he applicant Of future building weapon use equipment or devices which If a roof is installed without first obtainingan inspection, 1 'agree to remove
emit haerdous air contaminants as derined by the Hay Area Air Quality Management P
Diane? 'all new materials for inspection. Applicant understands and will comply with
El Yes El NO all non-point source'regulations.
- 1 hmr read t e ha- us materials iccli mments under Chapmr fi95 of the
- Califamw Hmlth .of Cod "ct all 533 and 25534.1 undersmnd thm
if the huilJing Jo and nrendy h:rvco I.thwhis my resrymsihility snmify the
paI
el he aloire tuna Wille, el be act prmr to i.atanee yrn alar ate of
nee obey. 6 - .
j� Signature of Applicant Date` "
owner
an
ariaega: ' All roof coverings to be Class "B"or better
- - 'OFFICE . .