01050177 CITY OF
. CUPERTINO
'BUILDING DIVISION CONTRACTOR INFORM F01054177
BUILDIIN/G�ADDRESSi PERMIT NO -
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OWNER'S NAME: ' ' ,y, APPLICATION SUB HATE. .
Y +I U jos a63
PHONE; - SANITARY NO - - CONTROL NO. '
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L❑i'00 ARCHITECT/F.NGINEER: - a BUILDING PERMIT INFO
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E d •BLDG " ELECT MECH
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i1CFNSFO CONTRACTOR'S DECLAR14ION ,a PEMOV.E y'„F ' 9 y.
I hereby offirren yI�I am licensed unde
77 sacl/0l p3l 9(rourneweed, I:
aozEI ihS NEW ,nll^F'EeTQ'ET”
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Is 1 III ff
. Class Lac kVale Connector
ARCHITECT 5 DECLARATION
wv�yy�� es d YVI .I Iln _ e I bl' J
OW NCR BUILDER DECLARATION /O
e h hl fl II 1 train n 11 r thet io 1 L' Law 1 the LLL
which
'g (S 1 7(RIBusinessdP f:' .Cdl Any
an r Ie
❑ wh h l p 1 I trial. p 1 1 n p any , in
pr i t 1 .❑ ppl If hp It fl y d.Wl and '
-555 mmn .I dp pursuant 16 th provisions nn c t , License La (Chapter 9 Sq. Ft:'.PloonArea - � 1IUal I
, (con..eneng withSel 7000) fD' 3 of(he R dP f: :CraI -
or th l h ,v pt lh -f d the ".
M1 f the alleged Vf .Any v ds, a ♦ '` �^
Sectionof �any applicant for a or
of I morc� 5'ban h ndred dallars($500) t. hi d;the ppl' a dvil'p penalty - APN' h ^`
FStJLt1 B4.J Occupancy,Type.
'°1,as owarror the Properly,or my mnploycer with wages as a,alrsnle...ln oe,dimr, T
will do the weak, ,ad dre structurer manded ,,off e for a (Sea 7104 p st $, -
Bu. " d Profession,t C d Th C n1 ', 1' L e pply m an L QI 1,tp"'i,,FOi) llfd}I€(I.Q115�JectIODS .
"- ow fproperty Whobid. improve,Ih d J 1 kti..salt '^
rm 'ghn: plv .p aaort,aah imp rme t mendedor f 1,0;3 .. PJ ERG
idle,oder ' If,h over,the bully ag, r npnof mv' Id within one your o1 t' '
rler n m owner nu warty"u h..emenamen ofv ovi gll,find be didam buena' !".103 _L1rER,y
mpr r t mrI ), -
Ir. , r g 'e r n:J t �t A'—vl04w -f.REHAR� r c,
t l e , t p (s 9044Business der c e i Th cu, e
';.AJ;IOHORa BOIrTS t -
conduct
Case does not apply in r property n n I N or imposes mercom
d whso,cvantforh p jects with a anI wn.(.7 r 1 p . nn1 t me .n it�fx, SEWER. .8 .WATER] 't
C t dances License a La -
'°°I m xa,nplandar$a B&Pcfor ntis' awoa. -e, �'.. 20e^.-, = UNDERFLL)OR.F!LUMB,1.NGj:,,
ownar - Dale ` F,1 r'03%,�^- .IJf nbE-'RFLOOR.,,,MECFIAN,I:CAb_+,waI,; -
' WORKER'S COMPENSATION DECLARATION t ,u: ws1:1ND.E'RF L00,R1y,;R9ME'Sy,✓j
' I heby at d N rally f ry f the following 1 1 al : 1,o205
e
UhIDERFLOCR .,T,NSULATTONr�i
° 1 have oil will rrairdlij, ' C fRl fC am:If' for Worker
Compensation as-d...;aw for by searon 37Bthe Labor eae, for, be c. vUCH ,W11IMHiT'Nh ,
peffmaraireeat the work fur whch did. . i,lslsnued, _ n
c40, xrA TLIHr & ORa,'SWOWFR4e*l+, .,
°il et I r" w kf c npansarua[nsuran y " dbyscti,n, r. ' ?f(I , - RQULRWx�MECWAN,I„CALz�.-
-, 3700 of the Labor Code,for the worn neoea of the work for which this permit is
_
issued. lrwnrke.,ca paraaagm,aran,eaarrarandrnrner
Policy are: p 04ryrr§Rf141GRd;ELFCTCR.I,CAL..^4
Carrier "eofir,M - t „054.1 'r•FRAM&'r .
CERTIFICATION OF EXEMPTION FROM WORKERS' . . e -
r COMPENSAl10N INSt1RANCF. \' ..�Pk IZIFi F�k. WCI,.DJ.I(aINC�v�
(Th' -act need nm be cont Icled if the l s for ona hundree Jnll ;o a -
.($Hunnne.,..l p °`nn +�.ve.n0axr-,W.TTNS,UUAT�[:Or N2r,
w�48, SWEE;fRCC1'
fyml atopc,f rma,o orlfor which this pe tales dl � E �TER,1'ORzI AT S
C,hallt npl r r p serum,aobject t .n worker,
tt�309 W
- :'t f tC II Date
^
Applicant
Ap - ,x14 SNTFRT�R I ATW . a >"..'
NOTICE TO APPLICANT It, ftreadinglh Crouton,
rE Y h Id
z, he m n m w h 'ate Lhon-rC J r .t r!'; 51„1r_ $f'RRTI Hart"Itlf�Tw,. _
hannwitn comply with such provisions n this permit aban be d - w Evoked.
4 - CONSTRUCTION LENDINCAGENCY
w'aIh .by H th tth I. I leading ons, thaperforn tr,.
; " t`�-stT' 54nt w' 'F�IIVfraL,-ELEGTRICAL.�SiE'NERGY;i
ly p ' i��e work eru a�,e holo prat ais"natd(set San,e"..ei 50cta:�r FdTNRLiPLUH&I NG.,ENERGY ,.,-46
Vz0 IzJ :Aae . 7'S47rx FxTNRI
W I ' 504„, INfal-�+,MHFt MI A1)NS,NTGG AIE.N_EFNREf�YRpGt�Y
nrrmlt I '1 anconsb cir information 'IT Wien11 g it,comply with all city and couirfy ordinancev atfw, relating �
"vM. .
;O r� tobuilding con,arection.unit he by authorize I nTi e. flhis city m enm upon
�_ be b tent dpull f p 1 tl * . 5fD5i , +t+FINAL-1; ELEC7IRSCRL,{r.;,. .
LF. 51 .nanite', dg rae tt .t Id ry dknpn may inlnnywayaCity of ct,ardu againsro °aidjr(�AR TE9I 1
v 7a Cita sey,aaaeoftn g.m,agorthis Perit f'ft5(�7 „FINRIp PI+UM$;I�NG :
APPLICANT UNDERSTANDS AND.WILL COMPLY WITH ALL NON-POINT Ia I�
SOURCE REGULATIONS Issued by: ,; _ .,
rzzw
C
Signature ofApprc'INc t ,dur Data Re-roofs 54kOo w^FI p �gty - '
HALARDOUSM\TCRIAIS DISCLOSURE "C.^n,.
weln ppl a I f n n' a , I x rh el n m material ' Type of Roofr 1511L1, ,r Ftil Rl(t1L F'LANN�I ISI t,�v -
as J f d who C pe I M pal Code,Chapter Y 12,and the Health anJ Safely i v :°Si514,I- T.Ful NALpL1HLNIC'fW�RF,Ss,?ka„y
Core.S d w o C.pa)
°v c No
All roofs Q,lge'inspected prior to any roofing materia] being'installed.
Will to applicant t maturing secapa,l use eyu p t d s which If a roof is installed without first obtaining an in I agree to remove
..I ha d t - 1. d C d by the Bny Area A Quality M nagemenl _ - '
Dol I all new materials for.inspecih Applicant understands and will comply with'
°Y' °M1 all non-point source regulations.
1 have d the hea/midutis materials requirements under Chapter 695 of lhc, 'r s t
Cal"fo H ITh&Safety Code,Sections 25505 25533 d 25534 1 Ind 't d thdt '
if the-'capital
obuilding d t um which
tenant,e ,air , . y rc p of a to Cor cat the
oOcc p' 1 of requ'r t wh ch must n ,al pr nr to'ss a of a een'rcate of
���•C�
" "'� Signature of ApplicanC� 1' Date - -
Z All roof.coverings to be Class "B”or better
ow II ad..ea agent � - Data - - - -
OFFICE� -