01040141 Cl TY
NG DIVNO
iSRION
BUILDING CONTRACTOR INFORMATION:
BWLDINGADIIRESS. - PERMITNO,
20059 Q-ENMA DR
141
OWNER'S NAME: APPLICATION SUR DATE
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]ONE: SANITARY.NO. CONTROL.NO.
zOO ARCHITECTIENGINEER: ..BUILDING PERMIT INFO
6 u E - - BLDG ELECT PLUMBMECH
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R'S DECLARATION r Y(co nmoncing
� Job DescriptionZH
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Date
a, { pCLA A[ N T;EFORARY POWER
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lot 1 undwirstroad ray plans houl he t,ald as cublic secords
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Licensed hereby
OWNER RUI DER DECLARATION
G � I M1 se afOmvh t l ps f tire f I t . :LicenseI w Tonne Q /
Cted following s.aa.(Sec, 7031.5.Business and Professors Cade.Any cityorcounty ✓ '
Be O which reyuiree n Penni,to wnstrnet,older.impmvc,d,errin i orc.,i any suuemm
Be thatarifihnslicensed laducat also In taehe provisions of for Cutedurmtt License Law
Comm,
(commencing with pmxaaon 700 OfTyvineor little Businescturss Land Professions Code) S Ft. Floor Area Valuation
'(cammencis excu ,Instep]INN nd,he vision 3 little alleged
xcuip ird.Any vCodn) q'
onhw he is exempt shcrefmm and fur basis ror,he allege)excmpnao Any violationnaty
of Section 7031.5 by nny applicant for v permit xthjects the applicant m u civil penalty '
argil more thin five handled dtdrars S50i - APN Number Occupancy Type
°i. t to p' Iwm , PI y to p . t _
will d the k d t h a n ,intended g i U c d For, (Sol,70,14.
Business and P f:: Code:The L , , License Law d :no,apply to an ASquired Inspections
Owner of pmpusy Whs h Id.or npmves thereon.o solidifies and such work ,rts
hielf -
Or.the,tgM1[Ill awn employee,,provided'it.('Loch iimprovemcris am nap intended or .
arrertsl fur sale,If.however,flee huiwIm
ing ar pmm
veen,is said within ane year or 1.03 — UFE R
a'nactlon,the owner-builder will have the hdrleput pravmg atm he didnnt bund or of ale.)
304 — P,OI.IGI-I EI_ECTRICAI_. .,
mpmve for pi at _- -
°1,as owner of di property,an,exdusivcly emnre'lar,with licensed ntmmeters a
constrict the in jell(Sce.7Bt4,Business end Prnfe,,load,Cndi The Caull mk '
Llwnse Law dncn not apply hit nn awnar of pmpcny who build.nr impmvc,,hereon.
and who wnwcts fur such projects with a atntracmr(e)licensed pursuant to the '
Contractors License Law.
°I Or.exempt ands Sce _ ,B&PIC fpr this reason
Own,, Date _
WORKER'S COMPENSATION DECLARATION b
In by II under penalty�Uf repay, th GtllnwinK Jeclaraunns:
1 have J Will a v l t a Cert . ut Consent, , sell'nsum for Worker's
Copp satin,, as-provided for by Swran 3700 of the Labor Code, fur ,be
perl'onnnnce of,he work fnr which this pemti,is drat,!,
❑ hvveadd will maintain Workntnlw
er's Cnemlon Insan
urce,os required by Sec,inn -
39110 or she Labor Cede,for,he perfor ianw of she work for which this Iwmd,is
,sued.My Worker's Cmnpensntion Insurance caner and Policy numher are
Caine Policy No.:
Cf;ICrIFICXUON OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tei,svi acre aot he pnpleded B me ,,all'ts fur one fandred di
G100)or less.)
1 verify shat In she performance Of the work for which this permit is ivsuW,I "
shall no,dandy any person in any manner so as,o Iwconu>vuhjec,at the Workers' '
Conpen ankOd Laws of Coliform,.Dote '
Applicant . .
NOTICE TO APPLICANT:11,ufee,barking this CeNific 1,of Exemption,you should -
z dconesubject nt the Worker',ContpnteuGnn pt isiape of the Luber Coda,ynuniti,t
Q Q fonitwlth comply with such p rvidons orhiv permit hill he deemed ravnked. -
CONSTRUCTION LFNDING AGHNCY • t^
a , I hereby atBnn that there is it c extraction lending agency fur he performance
0of,be work fnr,which shin palmi,Is issued(Sec 3057,Ov.C,)
Q Lender's Hand -
] z Lcnder's Addles
C.7 Q I certify that l have read this application aitd.etum that the above informmimt is
4w H vowels.I agree to comply with all city and wintry ordinmtces and state laws[elating
r) to buildingnmaneent,and Isi authorize representatives of this city in enter upon
�y fel the orbove-andationsed ordinary
f Inspection(We)trance t e 1 fy dk norande,,th
City fCper, cannot
F. V] Iiabil f 1 dg t. c s d p acs wh 1 toy i t any way r gain,said
U z City :cyUND of th gam - C—
APPLICANT UND TANDS AND this OMPLY WrrHALC NON POIM' `••�I� VVI
- S CE RE ' qTl NS. - �/1 155Ued by. Date l
r uinre m Ap an rce atntetnr ,—'`,•Sw"'h// _I y'D'ree Re-roofs
HAZARDOUS MAI ERIALS DISCLOSURE '
Will the applicant on Tran Wilding accapant store or handle mt,.amrus na,erial Type of Roof -
as defined by the Cupertino Municipal cone,Clmpmr 9.12,and,he Hoehn and Sandy .
Code,Scotian 25532(al'!
❑fiat °"°
All roofs shall be inspected prior to any roofing material,being tinstalled.
Will the appoeamnrfatmehmldateaw,pant u,ceyn'tpmen,.ordeviceswhich If a roof is installed without first obtainin an ins ection, I a ree to remove
nand ha ardoua as enmammams a,diehard by the Bay Area Air iMadr,,nand g p g
'Diaiee
°Ye` Ed Now all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
.` 1 have tale eta Safety
CrIne.tact 2 505,rocifluerrover,,a adder enamel e5s or me - .
Caleblin Health& of cuaCute,ave ate 2550A255.13and 25534.1 Interisland that "
if the building dtee not cum:ntly M1aveamnanL that i,is my mepanslbili,y to natlfy the _ '
wcupam of,1 7nnn he met prior m issunnea ar o Ccrtifevte of
Vccupa - _
Signature of Applicant Date
wear nnnrt:ea ng,nt Date All roof coverings to be Class `B" or better
OFFICE