01050157 ci TY DIVN
SIONo
BUILDING PERMIT CONTRACTOR INFORMATION:
'
BUILDINGADDRESS: - - PERMITNO.
ON WADE ELECTRIC CO 0117,50157,
OWNER'S NAME: APPLICATION SUB DATE
PAI I G320 HARt OOD— RD,f- ,.
• PHONE: - SANITARY NO. _ CONTROL NO. -
p .Os r
WOO ARCHITF.CTIENCINEER: - - - BUILDING PERMIT INFO
E tt� BLDG BLE PLUMB MECH
IJ
2 y Z LICENSE[)CONT'RACTOR'S DECLARATION ' r
1 hereh Ron that I am licensed undnr p g Job DBSCrI tion'
Oy Yv lnd Prueof Chafer, (canutencls - P -
p,��w with Sretian]OB01 of Divlsion9 ofthe Businevv and Professions Code,Wmy license
P in full lose on 4
°cceaseless { un.0 X70 ,,;=00 -AgIJPGRAIn,. �
3 nic cnnwcmr
ra
ARCHITECT'S DECLARATION
sadsg 1undenmodnay PIa'ns shell he,,oil,puddle meards
W. p O Licensed Pn,fsiannl 2 t�t� /1 �2 D -
a'a
OWNER-BUILDER DECLARATION tl� HALF.
I family affnn nm Thal 1 exempt Bit.the Contractnr'i em
Lce Law for the '
C?a following rennin.(Section 70315.Business and Professions Code:Any city or county MAY 2 9 2001
ce m which requires a permit to concwm,aIle,,hnpmve,demolish,or,epmr any structure
uy,ar_ prionoi¢ismance.aNn regtdres the applicant lor.such pernif in file a nigned statement
flan he i.licenced Part in the promsinns m the Contmmos License Law(Chapter 9 ', S FL Floor Area Valuation
(commencing with Section-101AB of Division 3 of the Business and Prof..ran,Code) q' ,
or that he is overall Ihembo n and aC oasis In, be alleged cseodita.Any violet ion
of Section ID31,5 by any applicant fond pemtitstbjects the applicant m 'a civil Penalty
nrRD III n
notmemmanrvehundreddollar,($500). Ap um er Occupancy Type
❑1 as owner ofthepro,cal or my employees with wages a',h 'r: I pe sal an, ^r -
will 1 the k and thea s ,intended B J f I (Sec 9044 - -"
Business aid Pa f.. Code:The c mmo,r L L does I apply to at Required Inspections-
-
�;owner of pntpeny Who builds,,,improves thereon,a td who does such work himself
r dnn,gh his own employe,,pmvided[hat such im......ncros am oat intended at 30!t. RIJI'1GH ;EhECT RII GAL r
offered for sale.If,however,the building or improvement is sold within one year of '
ompletion,the owner-bunde,will have me hmrtlma of proving that he did atnI build or 1501 — FINAL. -EL GT R I GAL ENERGY.
fmpmve for purloce afsele.7. _ E
p-rr. .la, Irt g dtr,mrc , fLI L asowner oftool 505F,,INALELECy,RLGRL,,
construct the project(see 7044.Business and Profesctons Cade) rhe Contractors - 1
Liver Law does rot apply to an owner of property who builds or Improves thereon,
and whn contracts for such Floods with o a dradif,) licensed pursuant no the r '
Cantermo is Licensee Law.
❑I not exempt"ail"Sec. ,B h P C for dais ricion - 1 1
Owner Date
WORKER'S COMPENSATION DECLARATION ,( f�� V/////At[//J]✓ vt,J „JJNN ••
I hereby afTinn under penally of perjury ane of the following Aedarotions',
❑ 1 M1 d voill maintain Canonical, if Consent el ll far Worker',
CulanNal,irion. as mavidod C by Section 39W of he L , Cosa, far he
performance f the a work for 11' pe t- d J: /q.� //'
111 have J '11 ma t Worker's ba l I the
' ,m : y ' Jh Section /J /V`,J/\t C_ 0 ill"" . �• / \ � �
3900 f d Lab Code,1 thel Inst ce ler work[ 'h bit this pland,is V (((
rested.My Wor'k•�e�r'�s Comp/oy/y/e�o�n�Imumna c d Policy mmmher.nr
C Tom—'R11 icy N,F(Q�i/LbC�
CP.RTIFIcAfION OF EXEMPTION FRZSMWORKERS'
COMPENSATION INSURANCE ,
(This section need not he completed if the permit is for one hundred dollars
($100)or less)
1 crafty that in the peff unmeant the work far which this permit is issued,1 ,
shall not employ any parsnn to any manner so its to became s.bj,ct to the Wake, -
Compensation Laws o1 California Dan,
Applicant -
NOTICE TO APPLICANT:II, it,,making this Coat ficam of Exemption,you should
become subject to mo Worker s Compensation provisions of the Labor Code,you must
QZ ..
Q far,hwith comply w,,It such provisions or this perm it shill br Jeered martial
(, Lill)F-r CONSTRUCTION LENDING AGENCY
a 7 1 hemhy v0irm dmuhcrc is n ,,a,,an(Sec. lending agency for rite lerfonnvnce
W
Leader's
work for which this ponnit is issued(Sec.3119],Civ.Cd
O, z Lender's Name
� z Leader Address a
V 1 cenhy that 1 have mud this epplicuion and s,am that the above mfomma.lon is - -
W tr a rta,, 1 agree m comply with all city and county ordinances and same Inws relating -
0 V mbuildin......ruainn,and hemhy authorise represemntives of this City to enter upon
>oW the ahova-nicmioned property for mspectimt purposes.
t..i Qu (We)agree tosave,Indemnify and keep harmless the City of Cupertino aguirssl
r ti Iiabildieyjud formal,,costs and aspens,which may in any way acerae agrind said -
Vz
APE, A tP P,N) IND W) . 'Ot
Ct
xequm oc t I the grunting ol'this perm /
S EG AT MPLYWITHALLNO r Issued by: / Da[e
Coconut ApplicarNiontraclor S Doc Re-roof
s
HAZARDOUS MATERIALS DISCLOSURE
Will me apphcamoraaure handingmeeopem stareorhandle hormai mated, Type o
as d,rncd by the Cupeninm Municipal Code,Chane,9.12,and the Health and Safety
Code,Section 25532(a)'f
oven ❑No All too inspected prior to any roofing material being installed.
Will the aofficial mfuture btdldiagecrapammsoegripar.,o,de"mecwhich If a roof is installed without first obtaininginspection, I agree to remove
ami,hatecum usair contaminants as defined by the Boy Area Air Quality Management an P g
Do...im9 all new materials for inspection. Applicant understands and will comply with
. ❑Yes ON. all non-point source regulations.
I have read the boz oder,materials recuiranen,s under Chapter 6.95 of the '
California Health A,Safety Code,Seem 25505.25533 and 25534.1 mnde,,dr d Wa, -
if Tdmg does am currently have it tenant,that i,is myrespondhil",In many the .
am of me regnhemam: reit moot v prior to issuance of a Certificate of _
empanc Signature of Applicant , Date !
er or anmarized agcol - � All roof coverings to be Class "B"or better
OFFICE -