01020130CITY OF CUPERTINO -
DIVISION
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CONTRACTOR INFORMATION:€
:. PERMIT
BUILDING ADDRESS: " '' ,
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PERMIT NO. - ' -
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OWNER'S NAMIir•
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APPLICATION SUB DATE
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SANITARY NO. CON'IROCNO. ,
ARCHI'FECTIENGINF.EIe: - -
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BUILDING PF.RMI'1' INFO
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MAG - ELECT -FLUOR MECH
LICENSED CONI RAC CH S DECLAR ATION
Description[tION `
I h y n that l d d p '
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I t]4001D sa Bu I'd' f: : Code, d byTrials,ri
is in full r r(jt
Lic .e Class �_y_ s L M
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ARCHIIECrS DECLARATION -
I midersmnd any h' II h bl'
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pl iretl p c nrJr ,.
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iLicensed J Ih f I
OWNER BUILDER DECLARATION
I herebyunion that 1air int 1 theC t_ t L' I forthe
'y toll . g e(S l pOl E5 B : df f .' C do Any iy ouny
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wh y n_ a tr tt tall P I I:1 p' in
yIure
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prim t t t alsolags theappl tt mhpartitl II sgnulsmte nen
- ' Incorrect o d pr a` nn c t License ICI p.do)
- S Ft. Floor Area ''
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inn ie } m Section oma) r i Profession, vi cotlx)
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orS t1 '. pt therefrom d!,, h;: r m u•gm pt Any violation
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ofS f )(HES hyuy wpx 1 n3 tthx appy' tt 'vilpenalty
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not mar I 1 1dollar, lssn0h ."
oad
APN Number
,. - Occupancy TyWg�
DI to p p tv y pir th g:.m
will I ih k J thet t 1,u t t I d � f[ eJ for wle ser. 7(94,
R Iced IIS ectlOHS '
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Business and Professions Code: The CouthicohiA Licenoo Law does not apply to an
rot property Warbuild, or ntrave llerenn uad whr 1 such work hi ,cIf
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or through h: employers. provided that .h' p t. art tit mended or 1
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offered I'1 It howevc, the btld'ng r in conand's- 11 withinme yinar ml'
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onplt d h'Id lllaox the burden of pnrvrh that hetltltot buJd or
Inp rpurpiniof o*.)
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'1 'r.;tl!1'r_} •_. Uhlt)E1'tl-1_OOR PLUMBING)-
F1 1 f he p u-111, I .' ly formandin, I hit licensed contractors an
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constundthepoudish . 7494 Brooms, unit P fiesurn,,C J .) 11 C l n .
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Lie Law does nnl .,,[y I, a of Property who bold 'npn ves thernn
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- �t; ,,II ENERGY
sJLyl f.� •._ I'-.I1 Y(-`I I_: �b'LUITIBI NO I:�hII:L' G ,
and who r, Licrus for sad, projects with a wnlracmr(s) licensed Pursuvm m the
arnhmrmr,Lirendi Lwo'
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PJ r' — f":I:hlFll_ 1='LUI'II3:I: hIGi'
1:11 hot eacmpl mWcr Sec. far Ibis macnn
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Owner Dole A/ ��� q9.q�
WORKER'S COMPENSATION DECLARAI ON
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I hereby affirm under penalty or parjury ore of the rollowing declamations:
1 have andwillmaintain if Printout, of Consent to self-imnre for Worker's
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Compensation, as Prrvwea fir-h, Section 3700 it the Indor Cade: for the
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peHormance`of the work for which this permit is iieuml.
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111 hirve and will maintain Worker's Caropeusadon lowhou ce, as required by Section
3700 of the Labor Calc, Tor the performance if the work for which this pe+'mi, is
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sued. My,Wmker's Campumation Insurance currier and Policy number are:
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Curries '. Policy Nm.:
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• CERTIFICATION OF EXEMPTION FROM WORKERS'
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' COMPENSATION INSURANCE,
(Than section need not he completed it the Permit is for ono hundred dollars
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1 Crory Our in the pribut iia of the work for which this per all is issued, I
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shall not employ any peter n in any manner so as m b uchic subject to the Workers
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CompensationLawsofCalifmmia.Date
Applicant
NOTICE. TOAPPLICANT: If, u0crneking'fits Clurd,ammf Esemptiun, you should
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become Isar lmtltx Woder', Compeusadon pnrvcio'of the Labor Code• you nmst
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forthwith comply with such provisions or this pernat shall be doenstl testified.
• - CONS I RUCT-IONLENDING ACE
IJ byahih that t dot agency fanhd performance
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of the work for which this permit is suul (See. 3097,C'y, C,)
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LerdesNie
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Lendur'xpdtlress'
4 I coli ly that I have read this application and state that the abuse information is
rren. I move 10 comply with all city and county ordinances acid state laws relating
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at building cructat Ion, and hereby announce aTownmtivcs of this city to ether upon .
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the shoveishoduned propery for inspocdon purposes.
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(We) gme toss .' d iifyandstop l I stheCly tifCaphotion a,hon,1
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hatolair,,tod,rachatI,c t nJepns which-r'y in any way .wrue vxans, said
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City rwo e (,film gaYS fthls lrrn't
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APPL-
ICAO UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT_
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Issued�,
SOU-
SOURCE REGULATIONS
.by C Date—,{�/�V^•1,
SigmatureofApplicartiContraetor - nwm
Re-roofs ... .
HAZARDOUS MATERIALS DISCLOSURE
Will the-pphccat or future ltuldlgnrr,paat store or hammenaamrsmtatrial
-.'Tape of Roof •- .
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_ us dein J by th C peH Mun e pnl CnJe Ctrtpicr 9 12 andth Ilcmh and Safety
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Code S t 5S12(a).
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All roofs shall be inspected prior to any roofing material being installed.
thoripplicarl or future building pats use ega p t ore ' e, which
at' l cal nadefined by
- If a roofis installed without first obtaining an inspection, I a ree to remove
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�Will
se n'n ih Bay Arco,
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all new materiAls for inspection.:Applicant understands and will,coinply with
all non-point source regulations. = .
1 have read the hvanlous araidals nequircmenm under Chapmr 6.95 .1 the
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California Health &Safely Code, Sections 25505,25533anJ 25534. Lunde and that
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-il the huiltling does not curtcn0y havnvtenanl. rent it it my responslbili otifythe
cerpant of a requlremcml which rues be ""' prior to Is anent a Co Illcatebf
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OwuPanc
'owner
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Signature of Applicant Date ^_ "
_ 'All' roof coverings io be Class " B" or better
m itmhoa<w axe ._ _ ' Date
OFFICE ;
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