01010111 CITY OF CUPERTINO - -
BUILDING DIVISIONPERMIT CONTRACTOR INFORMATION: ;
B ILDING A iSS: ' PGRh11T NU
Of K5
Oho n
(lW '5 NAME' \ - - I PLICATION SUB DATE:
PHONr:: - SANITARY NO. - COIsOR01.NO.
O0 ARCHITECT/ENO E:R: - BUILDING PERMITINFO
BLDG .ELECT •PLUMB h1ECH
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L O H I.ICENSE)CONrrRA6OR'S DECLARATION. -
Job Descri tion
O Z_C 1 hereby afDrm that 1 am licensed under pmvisi%,of Chapter 9lcnmriu rem, ^ p ,
wins loll Nn]pxB of Uivi+ion l ohne Businns and Professions cad a lruuu'''hcenx 'P ` `Q�, /N 1
Y f is in lull forte at fxr5� �`— � /�c /n Yt�) u / 1///��Y,,,��5
C a License Clau 5o Lic,t N-•!(— r_y_' Y `�\
at 0 N
Dam CnlitlC[_A 1 v
Am,fie'TECI"S DECublic meant -
t w°—y'�O� 1 undersmnA my plans shall be u.mJ as public rcenNx -
EEu c"p O Licensed Professional
e OWNER-BUILDER DIiCLARA'I'ION u -
W 1 herchy al irm tna,1 nm escheat rrnm he Contractors Liceme Low for Ina
C�< following reason.(Section 9031.5.business and Professions Axle:Any city or county
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which reQ ape 1 t IN 1 Iter p I 1 stn P�f ny INCmrt `
3_
prior in its .vane also dquiresthe applicant fsuch pc a rile it signed statement
thohe ll licensed m : tl hall foliations l the Contrarian s License Iaw(Chapter 0 Sq. Ft. Floor Area - ' Valuation
,,I emg w tl scat o,7000)of D'v s 1 l flim Ih,lncs E I la...on,C,nd
or pill(he is exempt ihertrrom and the host,for he alleged exemption.Any viola ion
of Section 7031.5 by any applicant fora permit subjects the applicant m a civil penalty
,if not mart mon rise hundred didic,($50x). APN,Number Occupancy Type
SOI 1'he Impar''Y - vply ''fl gsasm 1 ln
.ua ..
II I theA d thestructure t intended or offauld f (Sec.7194 -
Business it profession,Code:um Contractor',Lore a Lopil dive,net apply to as Required.Inspections '
xnerofproperly Who builds lir integral thereand ,hodlas such work himself
or though his own employees.provided that such improvements are not intended or - -
impIr Irl II h116 I a n :: IA fh yunf, ,
,pit the h 11 III ( N 1P gththe td ihuldlr
rep o,far PHs- f I ) -
❑I.as owner ofn p .ant lycontracting J c m t rs m
n,f 1 thep li f(S 7194 B J Polio Cm
r:)) r1 Contractor's
(l/ • -
Cee es J It ert
rI b' h o
I ld'I I parent, "
ct Licen. lucfor such
mi h p jots will,a a antmcnsrl.vl I n W 1 rn s' to the
Cont
❑I exempt unde,S ,B&PCfar flus reason
Owner
Data
WORKER'S C.OMI'F,NSA'1'I1lN DIQA RATION ,
I hereby aRmt under prally or perjury one of the following ice Emotions
C.I have and will provided
o Certificate Secti rel 3700 o m suLabor rc for Worker's
Campensnce of m pmvideal hoc by Section 3700 of Ihu Labor Coda, for the
pcai,rnaanee of IM1c work for which his pem,it iv issued. r '
❑I Itave and will)minium Worker's Compensation Insurance,as required by Section -
37N)of the Labor Codc,fur the pclentrall of the work for'wach this penin is
issued.MM WCo_t�k�.eLra'y_'Cnmpenrmiryr tgeu6ru4u>c`(et`Pc^�_art -Iur,number.,a
Cartier: —LERTI` EXENIPI IONN/[F,RROI SWORKERS'KERS' [rl/I ,
COMPHNSATION INSURANCE KE—RI t= -"l`l ,
(This sesta need not be completed if the permit is for line hundred dollars _
(SI00)or less.)
1 calory that in the pertbrmm ao of the work for which this permit is issued,1
'hull not employ I y pe„ob in soy manner so:rs m boon, stmiecf ru Ilru Worker,'
Conaparlmiun Luwsof California.Date
Apple.. -
NanCE'1'Q APPLICANT:IL aBcr makins this Cenilmme of Esemplion,you should -
Z...bac enc lubjecuo Om Worker's Compensation provisions of the Lahor Code,You must ,
fQ O furlhwhh vcomply with such in wholes,or this pcnnllshath he deemed revoked.
F - CONSTRUCT ION LENDING AGIiNCY t
> I hereby affirm that there is construction lending agency for the perrnmmnm
W of the work for which This pcunit is issued(Sec.3097,Civ,C.)
Q Larders Name
Z Landar'.(Address `
V 0 I canary flat l have mail this apleWithian and statement the above inlinmaion i,
031 E. correct.1 agree a comply with all city and county ordinances and stale laws relating - -
C U to building constructor,and hereby autborim mprc,amliive,of this cityea enter upset ,
�.r W the)nova-mendonal pmpvty or Inspection purposes. - •.
Ge (WO.Som I sus 1 'ry and o,l 1 less the Chy f C 1 s' )aguinv ' - -
N liabilities,judgments,ko t J expenses which may in any way licame against said
U City inc set aftM1 gmnfng all p.r tilA
APPLICANT UNDF,RSPANIIS AND WILL COMPLY Won ALL"'POINT o O
SOURCE REGULATIONS. Issued by: Date I'
Srgnufurc of ApplicanlA omrunnr Date Re-roofs
IIALARDOUS MATERIALS DISCLOSURE
Will the applicant or future wading ociallam store or handle hazardous material TYPE Of Roof .
a defined by the Cupertino Municipal Code,Chapter 9.12,mast he HmIlIr and Safety
Cuda Section^-5532q)1 I a - ..
❑Yes 0 N All roofs shall be inspected prior to any roofing material being installed. -
Willtheappliant or foam building acupam ase cquipmem nrdcviccs which If a roof is installed without first obtaining an inspection, I agree to remove
chat pool air cmennihmil'as d1fired by he Bar Arm Air Quality Management -
Di,iriet^ all new materials for ins ection. Applicant understands and will comply with
r
El ❑Na P- . PP P Y
I all non-point source regulations.
1 have rad the ham;dmis materials •qtu rM t:tandair Chapter 6,95ofthe
California Hadthi&Safety CIA.,Sectors 25501 255'31 had 25534 1 itudersmandhat t
,ifthe hfld g does ranCurrently l learn"I an it iyru,, :hrfyt , tiyIhu
cwp t f theI Tenons wh Jas mmofhe s prior toissuance of a Certificate of
Carnal s
Signature of Applicant - Date _
owner ar.amtnmda=d agent . D;,,e - All roof coverings to be Class"B" or better,,
OFFICE`