00070094 CITY OF CUPERTINO
BUILDING Drv[sioN, R T CONTRACTOR INFORMATION:
BUII.OINGAIIDRESS: PIiNMI'I'NO.
r
OWNER'S Nif E: ,. - - API'IACATIS) D 'r, -
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'HONIit, • _, r SANITARY NO. CONTROL NO.
O ARCHITECTAINGINEER: m - , BUILDING PERMIT INFO
s m❑ - HLDG LLF.CI' PLUMB MUCH
to¢y CI
v Z LICENSED CON'1'RAC'I'OR'S UIiCLARA'PION DeSCrlp[IOn
" In br urmt n licensed J p of Chapter 9leammensng ELECT' UF'GRA19� .
to -ith5 r 7(10)RE
3nOhm Bu. dP f.smsCodeaulmyice ase .? .
a g mfill f Jfft
se Lic is Class I' p
a,p a Date Cantracmr •. - n
��• ; ARCHI'FECr'S DECLARA PION - -
C p< I umlerMn nJ my Plugs shall he used adpublic records -as
i S p p Licensed Professional
%
OWNER-BUILDER DECLARATION
I hereby m lfinar that I ins esempl fiimt the Cm.lounn's Jachso Law bar The Ir -
ria following reaon.section 7131,5.Business and Professions Cale:Any city or county s
E x O winch requires a Permit I consumer.alto tp demolish. p ) t care - +
a. pri r t .. 'n 1 1 ._Ih pal' tI hp Ir I I 'y Lt m inn , ."
shah licensed p : art theProvisions 1r, Contractors L 1 (Chapter 9 Sq. Ft. Floor Area - �Valua[io
(commencing a ith Section 7")of Division 3 of the Business and Professions Calc) 4 _
or that he is exempt thommmm and the basis for the alleged exemption.Any violation
of Section 7031.5 by any nppllcrri fora permit ail po,theapplicunt to a civil penalty '
of not more than rive hundred dollars asap. AP Occupancy Type - -
r ❑I,m..wner til the pmpcnYnr•my ctnployms xim wttges as their sole mnme...tor,
will di the work,ind the amnmc Ix run Intended or offered t'or sale!Sec 7BJ4,
Business and Professions Cade:The Cnmtactnr s Licrna Law does not apply to an
crerofrpenywhohaldsmimpmvesthereon,and who does such work himself, 501 —. FINAL, E L E C RICAL' ENERGY
mmmngh his own empleyccs provided mot such ianuuvemunts ore not Imendcd or' - -
oneord for urle If,nowever,the building or Improvement is sold within one year of 505 — FINAL ELECTRICAL .
completion,the owner-builder will have the burden of proving that he did not build or _ ^
improve itis pamo.e orY:ue). .
❑1,a owner of the propcny,am exclusively contracting with licensed enmranon in, ''
construct the project(Sm.70,11,1,Business and Professions Gide:)The Commnnr'c
License Law docs not apply to an uwneroI,.,perry who huikh or impnwce thereon, - _ t r' ••
- trod who cumnw,for such projects with a s..I...ars)Reamed pursuer,to heCur - -
131 1 ori Llan c lax. - -
❑I ars q ,ay�HArcn,r this mason k
nets Date / ,�
WORKER'SCOMPENSATI ND//CLARATION
I hereby uflirm under penatty nl perjury uncut tlm following dcclarurinns: '• _.
7 I have and will maintain a Cenificate of Consent to off boom for Worker's y
onmenaitimn, as molded for by Section 3701 (if Ibe Lnhor Code, for the
serforaance of the work for which this permit is issued. -
❑1 have and will maintain W'orker's Compemarion Insurance,Lis required whiby Section
3700 of the Lnhor Code,ler the porl'onancu of the work fur ch this,coot is ^
issued.My Worker's Conmenavtion Insurance carrier and Policy number are: -
Comen Policy No.: „
CEItI PICA[ION Olr FXEMPI(ON FROM WORKERS' -•t ', °' '
COMPENSATION INSURANCE
(This section need not be completed it the pencil is for one hunAvd dollar, "
.(SI(10)nr less) •. - - '
I comfy that in The perfomaoce of the work for which this permit is issued,1
.11,1,11 nor employ tiny pars..„in any navies so as am M1coanii xolh.,to The Workers', - t
.Compensation laws of Celifomia.Date - - -
Applicant
NOTICH TOAPPLICANI If,after making this Cmificam of L cumnion,you should
become suhject to the WmUr'a Co lfwaririon provisions of the Labor Cada,you mus,
Q O Innhwith comply wins such Provisions nr this permit shall be JeanW revoked
fCONSTRUC'HONLENDINOAGENCV -
a �'c I hereby ullinn that there is a construction lending agency for the performance
of the.work for which this pernh is issued(Sec.3099,Civ.C.)
Lender's Nam. ,
n7, z Lender's AJdrens
V Q 1 renify mat I have mail oris mpplicatien mod slam that the..hove inhamnimo is _
Rt 'rrma, 1 agree in comply with all city and cnnnry orslinnnees untl stale luxe relining -
5 to bmiidingcorarucsion,and herehy mmtboriee representatives of this city to anerupos
} the shove-mentioned prmlmnY for inspection purposes. '
r Q.
(We)agree to rose,indemnify and keep harmless the City of Cupertino agaiom v
W lith Il' dg ts, r. J p -s which may t try y c against mid
U z city q nr.g t s I this scam.
APP C
NT U STA AND WILL COMPLY WITH ALL ON )INT IssUedb .'.
R( REG ION //� /�� y _ Date
Sigmatum ofappl eanvcommao/" �J-�,Vaale Re-roofs
HAZARDOUS MATERIALS DISCLOSURE -
Will meappueam or future hirltrmg oeaupant'hum in hau tic hard rialedm Type of Roof -
ns defined by the Cupertino Municipal Code,Cumrcr 9.12,and the Health and Safety - r
Cale,Section 25532007
❑Yes 11 No All roofs shall be inspected prior to any roofing material being installed.
Will the applicamorl'inure building occupant isce,m,soom ordevtceswhich If a roof is installed without first obtaining an inspection, 4agree to remove '
emit harardous air contaminants as defined by the Bay Area Air Quality Mmagement
Disbin7p Yes + ( ❑Nn ' .,all materials for inspection., Applicant Understands and will comply with
all non-point source regulations.
I hove read the hamrdous materials requirenants under Chapter 6.95 of the
Culifsm, Healthffi Snfcry CnJc,Sections 255115,25539 and 255,14, undcxlnnd rb:n - -
ifrhebuilJingdoesnmamern hay.alenanL that it is any reslv,niihi ly nx naify the ,
rcc t nlWit
the remen h men be mm prior to insuantt o a Ce Ocala of
1,Cy/T�(yy W Signature of Applicant Dtite
f>x'ner'`„a,lfF�mredasent t �/ ..ate .All roof coverings to be Class "B" or better