01020128 `. CITY OF CUPERTINO '• '""""
BUILDING DIVISION ' PERMIT CONTRACTOR INFORMATION :?
BUILDINGADDRESS, - Pv'- ! PERMIT NO u.
10050 c3 DE ANZA, BLVD
T
OWNIik SNAMF:: - - ., + APPLICATION SUR DATEl' '
.,,NIM_FTON1,.( ROUP
'HONE: n ,. - (" + ?� SANITARY NO: CON rROL NO. 1
X ARCHITECT/ENGINEER BUILDING PERMIT INFO _
yPp¢'�c w t Hitt ELECT PLUMB MEC H"•,
'Z m
LICENSED CONTR\CTOR S DECLARATION
S
' Z 1 hereby of in 0 I I licensed ed p ' ns ofCl pl r9 mo rid ming +, Job Description
-
9z�° wOSdnl000) IDI" nl',fthe Bun .ad Poloist.,r ' Cd adnrylense '.
�W� I` 1.11 cl„s lerr L a DEM0-A0F, EX-T-ST1NGSttjH0US ANDsrSHED
mm Comoliconk-,t -
p
ARCH[I'ECT S DCCL^A ON
SyCSd�` or 1 created my Runis shall he used as pubic records • + i -
ES o
OWNER-BUILDER DECLARATION
u3 1 hereby lir- that m I n e I- I Licerse,Law for the i
C Z Q roll ,o (Section 90 1,5,Emotes,and PifeW -Cddiu MY ty c mmy _
C which minutes a Evori,or corislacl.other, p d h P Y:lmLLare
' �m Pr I t q 'th ppl I[ hperfatl fl b l'
dIearenl
.a'+—
her he .lice oil indes h pmi,mr,of the CicdravhLi,ce,,La (Curter9 ”Sq, Ft. Floor Area �YaIU2DOn '
r, (c gwthS t ]W()ofDivision9 fthebusin anti P ress,ons Code) _ - •<
or than ',cluencta Evelmor ad the India fI he itIleged evermicia Any violation
of
e( oe l5t subjects the applicant I civil pc mh)
r n mhur hundred dollars 500),
APN Number - Occu anC e
,'t..
01,as owner ofinepmpertY,or it,emphtyer,win wagc.as'Ineh'ele cinnpenw(m, 3E901.0217 00 1 - - '
'
will do the k land the structuret intended or offered for sale(See 914,, - -
•Business and Prodessions Cale:The C License' Law does not apply to,it ,' Required inspedtions
ow I p p ty Whobuilds improves thereon, I d k Indoor
r h bhr. n ddltrl np t tintendedor
; SIF: - 11\lSEiFf,,7S;ON8,
offered I It,h vc Ih n 1 gimpede, t sold withiny 1 ,t...
t -
tclud,li,nor,heowre,hatildenwillh- the b derdvfp ' ,Ont tdidda,blld , v
u
„ps,1 '?"se f ). , . .
. 1
❑ fth p p ,y ly contract S will,licensed t I 'I
construct the in t(Sc 4
94 Business and Profictsions Code)Th Connector's
•,
License Law cluesnot ruplyit) f property itho mildv or improcesfl _
and who contracts har such projects with contractured licensed pursuam at the Contractor x License Law
❑Iu a exempt under SIN, j' ,H&PCfonhfs mann ,
Owner . .. Dole
WORKER'S COMPBNSAI ION DECLARATION
Ilercny affirm under pe,ally Of perPry Ole of the l II n deelafnllnnv, 11 '
1 been and will -
❑ maintain a CcnilSNti of 37 Isnot m Labor Coca
fnr Worker',
the� '
+ r
fe a nsweof he work
furl for by Section 3900 of tlic Lobar-Code, fnr the
perrnrmm�ce of the work for which This perm'u is ieyued. , -
❑1 have and will random Winston's fo p sat on i sufm tet as re'a'red by Section •' � _ -
<
37M of the Labor Lode,for,he pinduldmnce of the work for which this permit is
wed.M Workers Compensation Insurance canter and Policy number um:
Y p Y
k. ,
L Cam Policy,No. - -
CER I'IFICA'1'IONOFEXEMPTIO O n
EXEMPTION FROM
` - COMPENSATION INSURANCE f
('roils section need not be completed it the permit is for one hundred duller, -
(ilitto [less.)
1 certify IRm in the performance Of the work for whldhthis permit is is.si ed.l
aharlbod,employ an)pwasrai in my mun ter so as to Ferrule".a sect¢.,the Workers - '
• G lie -i Law's fCalificionno Date ,.
APPlleanl
NOTICE TO APPLICANT:If,after making This CmOfmae of Exemption,you duald -
z be hj tt theta k C pe. t frowarn,al @v Luhorl'n<le,Yon mush -
,z� O fanh ah comply with such provisions or this permit aMJI be deemed revoked
fn - CONSTRUCTION LENDING AGENCY -
�•5 •?!; 1 h uchy tiffird,IllI them construction leading genet'for the perronntmce
� of the wink for which this pened is issued(So, 3097CA,C.)'., . -
Q
Lender's Name
Leader',Add
- I coufy that lh nth plc I n mal,bile lhal ho.b.,confornmenin"
Lz F
courman.1 atfou n ply ,ter 11 cityanalIY 1 a L,are Il :s, Yogi ^ -
V tuba love formulefon ,inlyfchymth prucnmi ve flh seilymLnterupnn
r�
heabove r d p p IY I i t aerosol.
Ft' a es, bre rc d k p l ar I..the C ly I C P rf g IS't
FIN C/J .liabilities,e j dg L' 1'and Rp a e hen T y n lay 'y e vgni t t Id I � �
U APPLI ANIFFU D R theUNDERSTANDS
of thisp n,. , ' -
APIA(CANT UNDERSTANDS ANO WILL COMPLY WITH ALL NON-P INT p 1��s l// �•
SOURCE REGULATIONS —}-_ l/ ' y�li8/� Issued by \ 1 U. Date
Signature of Apprcan/Conlraelor .. - Date, •,. Re-roofs -
IIAZARDOUS MATERIALS DISCLOSURE. --
Will the N,licam ar future,adding ,nfad more or handle nazmdotis.;eatndw 'Type•of Roof
as defined by the Cuponinn Municipal Code,Chapter 9.12,and tie Heilk and Safety-
Code
afelyCode,Section 25532(n)?
0ye, °N All roofs shall be inspected prior to any roofing material being installed
W"11 th I pl , [alone n ld g p t cip t J ' es which If a roof is installed without first obtaining an inspection, I,agree to remove
e n t k ,Tau al coli n.us n.hi red by the Hay Anor Air Quality Management -
Distrint,-.. "• . a- albnew materialsforinspection,;Applicant understands'and will comply with- -
°Yen °Noall non-point source regulations. -
I h I,ad the h J : I l ret' rc ens n d Cbar our 6.95 of the
Caff lde Henlm&Safety Code,SuRn:25505,25531 and 25514.1-undersm a thea
If(Ile houlding cleas on currentlyh' a Imunl runts cry cNionsibililyf if)the - - • .
4 'c pan of Oe requirement,Inch neslho fel pr nr In is: some of a Cetlffuteof •
_H1� /o Signature of Applicant - _- i, Date -
i
OwMr or andmir.inglon nate , All roof coverings to be Class `B"or better -
"' - , OFFICE. .. .. _