01050197 CITY OF CUPERTINO IW
nun.DING DIVISION PERMIT CON .OR INFORMATION:
BUILDING ADDRESS: PFRMIT NO. '
21462 ELM CT. 1 01050197
OW'NIiR'S NAMB. `t APPLICATION SUIT DATE
TSTIU 05/30/2001
'HONIi: SANITARY NO. CONTROL NO.
w O O ARCHITI.0 PBNGINCER: BUILDING PERMIT INFO
y❑ BLDG ELECT PLUMB MECH
Y a
w_ LICFNSIiD CONTRACTOR'S DUCLARATION Job Description
pI hcrchY m'rrin that I am licenced tinder provision.of Chapter 9(commencing P
ad with SectiW70(IU)of Division 3 of the Business and PromsssionxCWe.and my license
'x 3 ismfmnfomeanaene` CONSTRUCT 2 BAY WINDOWS. .
d License Lic,p Z O
3 a H Daly_ Q� Canmmnnm m
t-p C ARCHITIiC`p S DIKE A'
w w 5 1 nndcnlanJ my plans shall nc used as pu cnNs
an
inn S p z Licensed Pmb,,ir al
OWNER-HUILDER DIiCLARxnoN,
1 hereb
i:i='u' y affirm that 1 am exempt Gam the Cnmrtcmr'v License Law for The - v
F.,Z< following rcaenna(Serino 9031.5.Ilei neo and Pm1'msinm Coale:Any city nr county -
I x❑ which rx,ine,o lermil m construct,alter,improve,demolish,of repair any sfracture
5� for n ils-. ante I- napire,th .pt,l tf Moons file.si,ifed,wremem
he,he licensed wat thep th c mi t Liver,Law(Chapter9 S Ft. Floor Area -
(a r algwthSeubr7000)oflSvsnn3ttitleR- e"adPmfussnn,Codc) q' Valuation
or that he is exempt tnerwrom and the basis for the alleged exemption.Any violation $4000
m Section 7031.5 by any applicant for a permit subjoin the applicant m a civil penalty _
of not From than five hundred dollars($5110). APN Number Occupancy Type
°I.as owner of the property.or my employees wish wages as their sole compensation 36200101 0 0
will do the work,and the amcmre is not intended or offered for sale(Sec.m3o,
amines led rral'evaam,Code:The Crimnl<mr's License Law does and apply to un. Required Inspections
ow r ofproperty Who hn'dds or improves thereon,and who does such work himself
r Nfuugh hi,awn employee,.provided mat .on improvements are not intended or 516 — FINAL BUILDING
offered for sale.If.however,the building or improvement ix wld within one year of
n..plction,dm owner-bind<r will have the harden or proviii,mat he did nal hold or
improve for pugmw nl'sa d),
°1 romancrofmcp ecny los y t f bwith l' J I (crew
'ot /
Ins project ],min in II f.. nuCd ITh C Tar's .-
Licamse Lm,does not apply t er of p Pliny no build,,,,improve,thearesor
and who mantral for such posdoers with a commaral licensed pursuant to the
Contractors License L
D Iran rxcpt Err Sec. Of&P CIrILiv
Owner Doc /
WORKIiR'S COMI'IiNSAl10N DECLARATION -
I hereby affirm under penalty of perjury one of the following dedamllon,: /
° I have and will molnlnin a Cenihcate er Consent to self Inman for Worker', _
Cmnpansatom, its provided for by Section 3700 of the Labor Code, Ibr the
penaborma ce or the work for which this permit is issued.
°1 have and will nmintaiif Worker's Cmnpennution Innumnec,as required by Section '
3700 or the LaNa Code,fur the performance mf the work for which this permit is
kmed.My
W�.orkeer'%Compensation insurance carrier and Policy number am:
Cu.ricn45/c '�FduA_XHicv Nn.:
— -C.H'1'IFICA'1'IfIN OP IiKF,My lva: FROM WORRIERS' ,
COMPENSATION INSURANCE
('Phis section need nal be cnngncmd if the permil is for one hundred dollars
($100)or lewd
I certify than in the wiformance of oho:wink far which this permit is issued,1
,hall nal employ any Pimm..in any,nome,sit us m bcernnexubjccl to'he Workers'
Compematbn laws of California.Date
Applicant
NOTICII TO APPLICANP,IL a0cr....king thin Cenifrac of Exnnplion,you,hnulA '
Z 2 boeome%abject it)the Worker's Co rapensairm provisions d the Lmor Calc,you anus,
forthwith comply with such provisions or this permit shall be deemed revoked.
.^n
CONSTRUCTIONtheresLENUI NG AGEgenc
a NCY
1 heresy arhrm that mere i a amm(Scan lending agency for the perlitnnance
Lethe work for which this permit is issued(Sec.JlH],Civ.CJ
Q Lender's Name
� 7 Lcndcr's AJJrao -
U I ccnify that l have Rad this application and\WIC that the above Information is
a sC. correct.I agree to comply with WE city and county ordinances and state laws relating
O !) ' ,,haildi„g cann,rnalon,and nearby mnhmhempm,<nWdv,,al his city lin moor upon t
L4 the abovementionod prolixity Tor Inspection purposes,
E• L (we)agree msavve.indemnify and keep harmleo the City of Cupertino against
Iii!) liabilities,judgments,costs and expenses which may in any way aamme again.¢said
U Z, Chs yes of grant at 'e
t
r S LI A ' USI IE RWILLCOMPLY
STANDS AND WITH ALL NON-POINT
III 5,30 d/ Issued by Date S
ata a p,con VCn once” Date Re-roofs
IIAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future nuading oecupam snore or handle he xrdoax anatetial Type of Roof
as defined by me Ciflomin,MMunicipalC,Ac.Chapter 9.12,toddle Health xnd Safely
Code,Section 255921x1" (
No s ^
❑Ye, All roofs shall be inspected prior to any roofing material being installed.
wB"ilao pplictmlorIntarebuwrungocenpanataegopmemordc,i«,,Inch. If a roof is installed without first obtaining an inspection, I agree to remove
eml,b.aJna,air carominons as ddined by the Bay Area A it anal try Management �' P ig
Dialrim]
°Yr v,, all new materials for ins PP
inspection. Applicant understands and will comply with
N" all non-point source regulations.
I have read he harallons materials requimanems under Chapter 6.95 of the
California Health&Safety Cale.Seclinn%25505,25533 and 25534.1 understand that
/ it the building does nal cmmmly have lcwnlnbar it is my m,, i hi l ity to and ry the
nein of Ilii rcyuinmmnW whmnmm
ich oen be ,prior to tasuanee W a CerfiBee or
0 cap1.
1u Signature of Applicant Date
( ran„dim
grain Date All roof coverings to be Class"B" or better
OFFICE