01050172 CITY OF CUPERTINO -�'"
ButLuiNG DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING AD DRESS: ' - PERMIT NO.
1022P DUBCN AAV _ e
OWNER'S NAME: - APPLICATION SUB DATE
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HONE: SANITARY NO. -CONTROL NO.
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C,K Z ARCHITECT/ENGIN
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O O ? - BUILDING PERMIT INFO
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LICENSED ONTRACTOkSDECLARATION N
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Counter
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DECLAR ON _
FKI rourecolluardray Plains shall hetcd a,Tbl' cords
y00 Li dPnl'es oral
OWNER-BUILDER DECLARATION. t -
I�i -1 herchy Ilffnn that 1 um csentpl front the Couln¢lor's License Law to,the - .1 -
. following retain.(Section 9031.5,Hneiness and Profession,Cade:Any illy or amity y` '
u�i Cm N'inch 9'. e Ill .til n p J III p y:in,�tre .. .. -
1 lfl a11f II njw ttl fl g d ca e l
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that he f Ip t o II p of the Contractor L La (Chalfant) n.
_ ,m g,with Section 9000) ro ,of the H aP r,a .cd). ' Sq. Floor - Valuation -
_ arthat n -: ptm r d.tn n f -u ll ged vl ny ' 1 f _ ",r ♦4aA,.. .,�y::.,r.:5;74300-- .
ofSection 7031.5 by any applicantf peordir subjectsthe' . applicant a yIp ally
I _of el narethanf„.n handled
APN Number 'Occupancy Type -
rCl
r dlulth,epr,arl ,ortoy enplyeeswith wages a.me -soldomm�amn.
' a[4P440
51 —
wl h work,a structure Iintended r IT J f (See.9044
Tipsiness
'ef nis Contractors Iice - L ° n trally 1.
;un r f property Wn drfp there d h J e h work R _ R1�eJq13u-i�red Inspections
rthrough,h f. • ply p ddo l: 1 p nnl intended 303,.— ROH ,MEEHAt offered f of If,h II building mpnnwtem ; UNTCAL”
Ithno f
`oiler .theto bld 'n have the btmenafpn,. glh-tnedidloth Idor ROIIBH ELECTRICAL
up frPnrp .ear:I >
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OI a of property, y .."ll,licensed nt Its to 505. — F,1hIRL:,ELEC;TR'ICAL >, 'u
o t La project(S 9I.a owBusdP- I : nC 1run C tunotn, - - .
License Law does not apply m a t owner of property who nt'Ids se Jousp rmeson.Can
9 t for such pn,Jeds with m adnr(x) licensed pt r anl,m the •-¢, -
Ct t� t I'�nsc Lml, su - .. ... �.
O I t." Pt under sec. B&P C audit,reason - or
Owner . Dal.
WORKER'S COMPENSAHON DTC1.ARAl'ION"
Iheteby nffimt underpenally of perjury one of the follotrngdueluareions:♦ , _ •�D
p I h I I l - t l t C t l t f Consent to 11 r for Worker", a a ' r-I N A L °
Co p r s, P y velloar . 'of 'We Lub., Code for the • A
MAY
_ pea 1' At 1h m'.pc ( Hot
'. ul. O 2 1
„ soil and wll ur
;tefora Worker's Coulloulat mfula.- y fb Sector _ - a.
.S9 of Inc Labor C d,fir the wrfor w of the weak for which this per nit Is - .. �• "
,led M,W kor's C nD allon Ill, c er and Pnl cy lumber are -f .�
Ca Tri
ier P, ' - -BUILDIN
CEIGH O I 1 R(lM WORKLkS r ' '
MPENSATIONINSURANCE , -. -
(Th' i tend not be couplet d if the pcnn t-s for one ht ndred dol lura
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SI00) -
I iy0ty that ill'Ile gerr to, of n rk l hich Ih pviond surd•I
shall roof track,a it,pn t in any na r a♦In wernar subject to the Workers
Compensation Lowsof Califnmle.Date r ¢ -
I Applicant,
NO]ICE TOAIII ICANT II afte,oseldr,th Croule,oloot 1'xampftn,you shah
Zhertile,object I (he W k Cianiverctiorpro,souns lifIficl.,bo Code youmist
firth 11 ply r.'th h p ' II s per n t shell be deemed revoked -
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CONSTRUCT ION LENDING AGENCY
W oI herebyt there L a on lending agency f r me performance
f the work fill Inch'his p mit is issued(Sec
7
3099 Cie.C)
• Leader's Nuue
z Let d AdJ e s -
�, I Ifyd tlha cd1h: ppl' Y uhc h f a ,
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correct
or e I
V ' p1YIhI agreeI county
d' t 1natio,
mbuilding t a n tl [
mpresentatives of(hi I t t -
t1ic M1 snot letyf :pct ptp. P i
'[y40. (W)a to or 1 Is andkeep h .th City,- tpdojer ug'. 'I
•,r h (tab fin" "rent.. I. 1 espouses which Y ill an y tame against:tit
"V Cny : l roofll N rNDWILL t
AT CA NI ULAIIONANUSAND WILL CO WITH ALLNON POINT
RCE REcuLAnolvs Issued by: Da'te I
slgnalufeofA, I oIt pan `'.Re-roofs
II MATERIALS DISCLOSURE
''" .marmmrennuantgmvtpamsmrenrnandlehamNaa.n;mndm Type of Roof "". . .
as dertned by the Cupertino Municipal Code.Chapter 9.12,and the Heath and Solely -_
Crew:Se6ti,an 25512(a).
or- ON,, - All roofs `shall be inspected prior to any roofing material being.installed.
w'u m ppi t r t n 116 n qn'p t d ° a wn'm If a roof is installed without first obtainingan inspection, I,agree to,remove-'
endth d nil I.asrefined by the BayAeaAr Quality Mtugener, p
"i'' all new materials for inspection. Applicant understands and,will con, 1, witb,
❑Yex °" all non-point source regulations. PP f compl,
11d the Ir N oat I: q -t:mWe Ch pt )5. I me _ -
Callf aHe Health f Iy d Seel .25505 255q anJ 25594 I In'1 r Jthm
file M1 ld g does not 0y h_' utan ml ll 11 . ttY resp bILW nmif this _
oceupa I f II req or
t -hh nmt 6 1 pr m Issl Certificate of - t
,Occupancy. - r p: - - ♦ - .
5 Signature of Applicant Date
owner or aunt -.ea ltgon -', Date All roof coverings to be,Class "B"or'better
• w OFFICE