00070023 CI'T'Y OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
HUILDINGADDRESS: - ^ ' ` PERMIT NO. '
OW'NER'S NA s-r CRICKET HILL RD
APPLICA'I'10 I'.
PHONE: I• _n - -, SANITARYN
8'63-o�.. sb .' Q�L�.-.' c1.r a b •
�00 ARCHITECT'/ENGINEER: •i - - - 7 BUILDING PERMIT NPO
% `'BLDG ELECT LUM9 MECH
LICIiNSED CONrRACrOR'S DECI.ARATION
z z 1 berm ❑Inn ohm 1 am IleensN under 1 g - Job Desert tion -
o�-o ra p : snfcn- t ur ,Insrn P
F Fud wlh Section 7000)of DiOkitm 3 ,f0be Bmim,OwdP exonarsCoca,and any lcetse
x f_ Is an full force
a°L1 L cn—eC
Date ardor
— ADD ON R,/C
O
ARCHII'I! toadies
i U.blirecords h g 1 understand my plops shall
Its,Dud us publicc mcoNs -
�Y
OO Licensed Professional
ES o,LL OWNh:m ewe LUEIt DC Inc era PION.
t3 1 naso n(finn that 1 uln exempt fmin Hut Cmnmx Ccx License Luw for the
C_Z< which
manna pan
(Section7031.5.Boniness and Professions Code:Any city structure ,. ^
Y-i D which requires a permit m conmmcl,cher,improve,dvmalish,or repair any mmnure
ca I-
!2 prior t t I, minutes the ( h tI Illsigned:l'nnot
,hill
n i caused : ll to the ponvisionvorhe Cianaractor,License I.0 (Cloplcr9Sy. Ft. Floor Area Valuation
(commencing with Section 7000)of DivisionJ of the Business Ih dfe' n'Cade)
,,,,ban he is exempt therefmna and the Ire, far the alleged exemp inn.Any violation
of See v n 7031.5 by any applicant fora permit sobject,the aptibrint to stusil penalty - - Qceup e
or not mom than five handled doums($100), . APN Number '
❑1.as owner of Ne pro,st on nycmpinyees with wagcsas Nelrsulccompm
cnlion,
sdr
will do nae work,and the came is not intended or uffered,for sale(Ser,7N4, 34?_3500
Businese and Pro(ewit Cale:The Cor Litt.,Law dons not apply man •s, "Ruired Inspections owner -
of prolarty Who builds Or ilnpmven thereon,and whai does wen work nhnselr
or through his own employees provided that such improvements arc not intended or
offered for sale.If.however,the building or improvemmrs sold within one year of 204 — UNDERFLOOR FRAME
ir completion,NP ownuohudder will huvetha hardenat losing he did nor build or -
niprnvefmpnaposaoloux). 301. - - ROUGH PLUMBING
°1,as us net oflbepropcny,am exclusively contracting with licensed command to 303 — ROUGH MECHANICAL
consumer the Indecl(Sec.7141,Business and Profe.emn.Coaled The Contractor s '
License Law dnesmat Ind,to i owor,orprnpany who ho Joan)in......a,tnrrcian, .304 — ROUGH .ELECTRI•CAL
and who mntmdx for such pa,jecls with a cunmtnnrlsJ accused pursumd Inthe -
Contlnctoe,License Law. 505- FINAL ELECTRICAL_ '
°I am exempt under see. ,B ar P C for this mason - -
Owner, Data 507 — FINAL PLUMBING
_
WORKER'S COMPENSATION DECLARATION '508 — FINAL MECHANICAL
I hereby alRrm ,title,'penahy of perjary one of the following declamddm: 514 — FINAL PUBLIC 'WORKS
❑ Lhs and illmin ' CertificatefConsent l II' f W kers. Az'
Co pe :tit n pn 'foil f by S t Jrho f Ih LaM Cwt f thepier) fN kf h hlh.pe t . .ueJq11 h d ll n,' t W rk C f h s ro¢ ) red by S tion300 I Ih 1 d r Cpm f r the pert n f In work far wh ch this per it is
issued.My nrkers Comp, on warrant, pier nd Pohcymmher are.
Currier:_ XEM]I[ON-R39tb �Ol II II I //I '0x/� f, 1 .O✓
"C R'111tiCACOMPEN COMPENSATION
INSURANC WOIiK]iRS' /l//',tpx•�y,. .1„a /V/ry/y ,
COMI'CNSATION INSURANCE `✓l Il//]/"JArj/ `
(1 his arnarinneed not be co.dilated it the Bernall I,Lunde d- III( . .1
(5100)in les'.) l '
1 con ify'lati,in the mmance of the k far which this ismarr 1 is :s A.
shall am employ any person'n any manne,so as to huome subject m the Worked'
COna,prea,union a�y�,nl C f ia,Data
„ I
Applicant
become
TORP LIC If fl kinethis C rote le ofExemption.y hoard
Q � her hl.py the k C pe u p dee WM CM y oust t•
forth th ' aplY wloh:_tip n nth-x IMJ'ml bll bed I conked. - -
z .
F, CONSTRUCTION LENDING AGENCY'
1 hereby anima that(here is a cars ( .lelen gygmey lar the parfommntt
o.�. of the work far which this Penni)istssu 7,Civ.CJ -
S (� Lender'x Name / J -
z,Z Lender's Address
U 1 certify that 1 have rand this application and state chat the h ihumeri
tmaril i agreeta oru,ply hl ;,It day and county hat ce,t ct.mt la lalny
V
to buildingconstruction,and mss y authorize representatives f this cayto aper upon
r� the above"mentioned property for inspection purposes.'
F. L
(We)agree to save,indemnify and keep h :the City of Cuperino against
CA linh'I'f ynd,onern, inst, captcale,.1inch 'y in any way accrue gains,said '
V Z City in consequence of the raafir,ol this partial,
SOUHCEREGULATIONSWITH Issued by: r Date
Signature of Applicant/Contractnr Date Re-roofs . -
HAZARDOUS MATERIALS DISCLOSURE, '
Will Ne ap,fmm or future building lecup.lnxlum an handle havnlous mutedal Type of Roof
m defined by the Cupcnino Municipal Cale,Chapter 9.12.and the Health and Safety '
Coda.Station 25532,dr, .
ID Yes 11All roofs shall ba inspected prior to any roofing'material being installed.
Will tn pplicant mandate miring occupant useequpmenl or ties iceswhich If a roof is installed without first obtainingan inspection, I a see to remove
cai,h contaminants .defned by the Bay Area Air U fly Munugcmem - p �',
District?, all new materials-for inspection. ..Applicant'understands and will comply with
s� °} s °x all non-point source regulations. -
1 have mad the laricandoes materials acquirmicaus under,Chapter 6,95 of the
Culil r II hh&SUCryC 5 t ns 5505 255Jga 425591 I 1 't dlhm _
Ism b Id' gds.dol oleo' trio:nay p b'i't t notfy the
cecupam N'he reyulmmem whit h h must he I e,I prior on issuancem
of Ceficme or IJO./1 ��a=a[.fl� L.: �V
Occ pa cy (, 1 - „ c. .. .
Signator of Applicant Date
o moron)or dagan( PnId T All roof coverings to be bassf`'B"or better
OFFICE. ,