00070109 CITY of CUPERTINo CONTRACTOR INFORMATION: }
•.nmLDINC DIVISION , .,, _ PERMIT
PERMIT NO.
40
'UWNER,sIl4EA_CHFH 0 - 'ly APPLICA'I'i NSUR DAfIi
20L of
i
G SANITARY NO. CONTROL NO.
'PHONE.'' w
is
.� ARCHITECT/ENGINLCR• ( BUILDING PERMIT INTO
''C�a O_ v.s + • 'tBLOU ELECT" `,PLUMB MECH' -
I 17—d
ou
=vo
o� c LICENSED CONTRACTORS DECLARATION T b Desert tlOn
�o IherebyatnrmmatIambcemea d provisionsfen Pte 9( a WATER HEATEk p r
ro t+m re on 91a0)if Dlvison 3 of l he Bu dPufaa Cdn andny liwusc
s' fall mdelect •• ' -
�s ¢
License Class -ECM / -
3w�
Data Craft
-
ARCHITECT S DECLARATION _
�j 1 f d f Yplan,:hll be cal public acrd -
ce in Laurasia]- Professional
''°•o OWNER BUIL DER DECLARAT ION •, y ' s
�7= 1 hp by Il 0 rl - pt f m tM1 C r t L a L f 1h _ F
"rail -g (Sct 9031.59 ' dP'f :Col Any ty r ty , <.`
wnh y . � ttt construct, It p dnlid p y.ttcure
a 3� Pri t t c al 4 - .'he effluentTortola p mu l l`.'y d.t mmea . . _(
morn I dpursuant t t provisions f(he e t t L I (Chapters - S F . Ploor:Area • Valuaton'-
(u. g ''th Section 9n(a) f D 3 I tireB d P f Code)r 9' s
'or Ihm he 1.c pt th -f J the F the all b J d A y. .lobo n
of Section 90315 hY any applicant C permit subjects the applicant no w civil penalty a v
I t ore than Fivehundred n Ba, (S500) A a Occupancy Type ,
r
❑I as owner of the property,or any employees with wages their sola compensation - ° -
ill a thek and me structure is hot ate,ded or Ifered for.ale(See.70T . 502. — F I N -
/Ba 1 P Posi C d The C mr et- License 1 aw es art deftly m an _ i
owner f property Whoh Id improves thereon,and whodoes such work h aselr 5121E GA$ TEST n
or th gh h'- employees.prcv den met Sieh improvements e a intended or
•a0 wr .Irh to ntdang or mpm,enem is Id 'd't Lup Year or 507 - -,FINAL PLUMBING - .
n pl t on,me owae hu lder will have Ed bo den or pa v ny door r head not auld or ..',
+improvoforpurpoeapfsale). °• : •+ "
El 1.a.n ins 1th p p tY I :i_-ly i i6 mlice d- t others to t' .}
-construct Wr project(S c-"I044,Busanr. and Pn fessi ss Gids)The Contractor's -
Lic :el does lot pplyt-an r fpiap ty h mild lap, .dereon,.
and eche toidowts for such puFol,with amrror(s) tensed pursaml mlhe _ I
.
Convfactors License Law - - -
❑I am exempt under Sec. R&.P C for this reason,
Owner 'Dm �
WORKER'S COMPENSATION DECLARATION ,
"i Ih hY oaf d IeIty fP Y f0 fII : 6f i and will mountain s Ceri fc t f C msent It if insure for WLrker s .
-O Lhuve a - -
_nnpemmican as provided,for by Section 3]011 of me LUM1ar Code far the
mfrrnance of the work for which this p (s sued.
,El I have and will nmintaio Worker's Cmnpnsr itfon hvruronce,as required by Sondra.
390(1 of me Labor Cale,far the patlrnmance of the work for wh'mh'Ihis pennhIs
sued.My Worker's Compensation fi,moncc carrier and Palley number are:
is 1 -
'.Carne, - Policy Nor: r+ ' - - Y.
CERTIFICATION OF EXEMPTION FROM WORKERS' ,. - -
COMPENSATION INSURANCE,
(Lis section need not he completed'f the terrains for'ore hundred dollmc
.(S 100)or less.)
r .. .. I
Icdlymf' th premonition,nn the kfmwn li tl permit Ince 1'
C II e L en ply y p y m become M1)" t in the W rkere
Compensation Laos of Cardenas.DataAppl
;
NOTI I -
NOTICE TOAPo the WiT 11 ft k gn sif ate fE 1 pti y ushould - '
z be h vmd,lomeWrk laCup n. t provisions tflhlhr revered you oust
0 fonhw'm annply with hp sonxo (it,,pandit fiul l he do cdrevoketl. _ - -
F,� -•CONSTRUCTION LENDING AGENCYf ' ;t
' I hereby affm Cut there is a r nstrurt on lenduig agency for the pero m nee Y
W "Loath kf whim lh 1 nil is issuW(Sm.309];Civ.CJ -
P. ❑ Lee N ,
Lc e Adl�s _.s •
C) C I en fy that lh e ad thisppI f d state that h information -
GL Ey cr t 1 y t coinply w'm all c'ry d Countyordinances' d state 1 ad t ng '
Q:[) rub lid nhroutruun and hereby aim representatives ofillsoty td"ena upon • ,
(1] ' the above me eioned 1 ,e ty is,, :pet p p
(W) g t d fYadk lh I.:O CtY fCPI &mal . „ �•
V] Iitu I 1 judgments, t d 6proar, ,rich may in air, y avenueagainst said
U ,Z City me n.e4 core rem g tin6 of tl seer ti t. /y'�/1•r
�•�' APPLICANT UNDERSTANDS ANDfWILL COMPLY WITH ALL NON-POINT ISSuedb Did
SOURCE REGULATIONS - 1 - y'
Signmum of AppliommoTmarradicarHA2IARDOUSMATERIALS DISCLOSURE, 'wi Date Re-roofs
' Will me apple 1 future- n rung .. p i.t dandle incurious adeno Type of Roof .. _
asdefnedh meCupcmauModiprlCodi,Chamrr9.12,nnd t he Health and Snfety
Code Section 25532(a)" -
❑se, El No All roofs shall beanspected prior to any;ioofing'mat6al being installed.
rf .n ,
w u In npr ant I t -n "mi;g occupant aeeq pm t re wii ori If a roof is installed without first obtaining an inspection, I agree to remove
en t Iranian., r ram n lot:as drlin d by the Bay Arca A r Quality Management �,�q
D'h'c + gall new•materials,for inspection. Applicant understands and will comply with
❑Yes' ON. %''all non-point source Degulahonsa
_ I have read the haaad u. moulded requirements.un der Chi 6.95 of the
'ohlrnia Health&Safety Code,Socurm 25505,25533 and 5534 1 understand that
'if the building does not currently have a learn[,that it my responsibility to lordly the
tet pant of the requirements which must be net prior do's f a Ccn f lel -
°rop°"`y - _ Signature of Applicant F.Y, Date
Owner or aamar'eeJ imam _ Ome All roof coverings tf be Class "B:'or better -
OFFICE „