00120044 CITY OF CUPERTINO
CONTRACTOR INFORMATION:
BUILDING DIVISION PERMIT -
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OWNEIt"S N,MIC.I ER - - APPLICATION SIB DATP
PHONE: SANITARY NO. CONTROL NO.
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n eiZ ARCO[I H0'IENOINEER: ,4' ALONG 1117RMII 'INFO
p, py _ BLDG F.LECT., PLUMD MCCH
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F, I ICFNSLD CONTRAC POR l UI CI AI<AI'ION
p r e,e ns Job Description
o z 4 n I I l y iP d t l I ceased t pr n:of rl 9 z p . .
rrmCw x'05 i' 91NX01U J fthc Bu t,.- W1� fuv��qpl syapd nyl care
�ySj LaIlloneandellec. VI ❑D REPAIR
s N
Lica
class ,Lie.« V
n e-a ale s ' Conn.hEh
in ARCHITECT'S DECLARATION a -
tD 5 1 understand dry plana shall he used as public me...A.c
w, .'
rc p o LicenseA l'n,fesaionnl
a•o i OWNER-BUILDER DECLARKfION
=•,n I tonal affim,Ian I a.ce moil(roan the ConmikoWs License Law for the
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a following maker.(Section 7031.5.Rumness and Profeednns Coi Any city or county `
E F,Z which requires a Perrot t t I It p < den li.h p y t erre .
i3F$ Prior to its:. L reclaim,th aPlilcart WItell perinoo.file sAii,madArn,ancla '
(n:tt .alp a Ih p Ito t t i 1 L Ins ode) Sq. Ft. Floor Area Valuata&
(,.at arcing ahs I )ECO) f e n 3 Ire II d P 1'.- ns Code) _ 10
or toad he a 1.opt the vfro li and Inv has s for Ihv at,(In. vac ,t on.Any violation - -- Gv-
nrseed,.aa Ynil s by nor apprram torr a panda eanJmi,d,c upplinatn m n dvu har,rny -
ernal cone than 0vohundred dolmm(ffi500). AP,i,,] 11u),j r Occupancy Type
❑1,It'ownonIfme[irofnrtY.rrmyea,plryee.with vogeXaXIllsol lletacipenaminn, •56�11'C3VIj9. 4lV.J -
will no the rk ]the I I t intrad,al or offemdl cale se IIkJ - - - -
n ,arJlnf is Code. G I' le, thick 'tear ° `� Ioocromy Wl p es h 1 1 Jsch work l neelf 304 ROUGH Required Ins
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or through his own a nployee.,pinvidul that such mprnve nems art not intended or
nn'ered11), ale.If,hawofa.Ihebuilding ,,imprnvcremisoldwithinnreyearof 501. FINAL ELECTRICAL 'ENEPGiY
mrmplcdna,the a,a'nenhuildcr will have Ibe burden of proving Nat he did nm mild or
proveourpnrpn,edrame.L 505 — FINAL ELECTR))yTTTCAI_
❑I acrid t pentexclusivelyofp ta t oWild d I tarsen.
continuer the i )a(S 1111) c i s and P f ons C N:)The C tractor's '
Lacca 1 1 t apply to mj Berth a pony who) Id. a♦npr theater,
and who Contractor',License n. for such p jecc with t l Is)licensed P t ar the
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❑I pt oilers c. It&11 C for this cancer
Orel Dov . 2/� �•a./� '
WORKER'S COMPF.NSAI'ION I31,CLARAI ION r \ -
II shy Iltrm miler penalty ofl,crp ray ,♦,o r the ldhwib dwlarutons:
7 have tun, will nailed n Cenifecti of Consent In nc Labor
lin fee t'e
'un,pracarw on, he provided for by Section ,i... rl' the Lahnr Code, fur the
performance of the work Into which this Permit is issued. -
1 have and will maintain Wrrker's Compensminn In,unince,us rcquircJ by Section '
31C(I of the IAds Care,for the Performance of the work for which this Permit is -
issued MyWenrkcrs Compcn.anion lnsumntt ca(rmd'r�ieyrvaPolicy numMr are:[,(/
Carrier. Policy NA.✓v -t�`o
CERTII'ICATION OF EXEMPTION FROM RKHRS' ' r
COMPENSATION INSURANCE ,r f
(Th'n seniors need.,it ire I.In ed if the fpmtit is for one Wadmd dollars
(SIIXI)nr lass.)
I renll'y Ihm in the'unlikmance of the work lot whirl,this perndl Is issued,1 '
,hall nm,...ploy airy person in any manner,..a,in be n.hlat to the Workers' -
Crn.pen.atior Laws of Oulirnrnir.Dre erm - r
NO]ICE'TOAPPLICANF If,after baking this Cerifeam of E brain ,you should
heeonm erhj,el to the Wrkee,Commisre,
Compensation pvof the Luhur Codeyom
, u ust- s
Z O forthwith anu9,ly-I'll such Pmmiliar,or ani,permit,hall be d,enal revoked.
f✓ CONSTRUCTION LENDING AGENCY
a '. Iheieby alBm,that there is a constmerinn lending agency l'or the perfarmance
W of the work far which this permit is issued(Sec.VO,Co,C.),
li Q Lender's Non,
.7 Z 1<Mcr's Adl .
Q I certify that 1 have read this application and nate that the Whom Infom,rion is
F.o rorrecr,1 agree in comply with all city and county ordinance,and state laws reining
V t building construction. dh by authorize representatives fthis ctyt t upon -
r� rhe ahove-inennionsd pation,Farn pectin
IM16 t c rl rY dk phrntle':theCity fCperi gidst
W I''bit j I6,c n I J pe se, ha h t uy , any y a c ga nn said '
V Z Cny nw of ah t g I'this lit 1 -�'
APDL u U f, c A WILL COMPLY WITII All ] P(INT Ito
Q sued by: Date
si"anar n A -ea tecrn Isar —� Dann Re-roofs - -
HAZA DO US SIA'1'ERIALS DISCLO.SURh
Willlim upplicant or fnum huildingocc ixturtuarc nr huddle hazaNnos mnedal Type of Roof
as JcE real by Ihn Cupeninn Municipal Crrc,Chapmr 9.13,anA the Hcallh anJ Safely .
Core.Scetion 25532(.)?,
OYe, Osla All roofs shall be inspected prior to any roofing material being'installed.
Will the applicant(it future budding occupant nm eluipinent or devices welch If a roof is installed without first obtaining im inspection, I agree to remove
emit hazardous air contaminants as defined by the Day Area Air Quality hlanagement
wriml all new materials for inspection. Applicant understands and will con I with '
❑Ye, ON. all non-point source regulations.
PP p y
• I have read the nazardnua mnerials royufrcntetds under Chat 6.95 of the r -
Colifomiaileallha9safety C It Sections"I",35533 and 2.553♦.l understand that
'I lheh II J not came ly me arnard lht t : yrosp hl lyt airy the
Iwcup,m t •tncar x un b n pri r t C n'licam rf
ilaup y.
6 Is Signature of Applicant Daie ,
Gw, , a 11 ,r .se - - I Oce, All roof coverings to be Class "B••or better
OFFICE
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