00090120 CITY oVND
ISIONPERMIT CONTRACTOR INFORMATION:
BUILDINGADDRHSS:/0 y/ �f„ ,. PERMITNO.
cwpvig��I370 CA
OWNER'S NAME: 1 APPLICATION SU13 DATE
PHONE: 10F,,89 FARALLONE DR MI EI_ECTRIC IMG SANITARY NO.L4009,L(1.LB) NO
_ e 1
C K 2 ARCHITECT/F. L 1 6 PER fIT INFO
Fuoo `'��E""ERA -RUDOLFO G AND- V OLETR- 5255 STEVENS CREEK 'LUG #.-E i��JIP1(dld2OOffH
��❑
i) ❑ LICENSED CONTRACIOR S DCCT ARAI ION I (Lt QJ�1 iFr�r-01 Q10Inb Description
I hereby affhr n th a 1 am licensed u d pr of Chapter 9( ml tune ng escrlp
H �ne will Section 90007 of Dorm 13 ef the Bul ..md Profictlin.,Code,and at,llcense
-,fa full mose and of h
z a
License Chis. /J L b �-!
Daft Q10 S .QC r _
AItCHITCCTw DECLARA III.
1 undersmnd my plans,hall he aced os publle rncnNs" -
se
aii—`oo IuLenaePemssional
' iOWNER-BUILDER DECLARATION
Iby fn mat l ,ausmapman C t rs I forms,
SERVICE UPGRADE TO 200 AMP
following ic I ' sR , d P . i n-C 1 Y nam
hh q permit tcont et.tiller,improve,detholish,or repair
any indicate
'
mens r
aim pros t a' t q pr ,applicantf Ihpe liricsigned,wrme9 ,
than Irlicensed p . amt ton Ithe L t t L W (Chapter de) S Ft. Floor Area Valuation
tennl,he ,e win Srileat erefor inial D'v's 3dlhe Bged exempion Ani'vICada) q'
or that he is exempt thnefnnn anJ ear bncir for the alleged exemption a rival a salty -
ol'can imn e dom by any applicant fora 5000th subjects the applfcum m a civil penalty
•
nrnot men man ova Initiated aounrs(ssoln - , APN Number , Occupancy-Type "
❑I,as o t mo.f the pmpeny,or my omployees with wages as meircnle wmpensution,
will do flet work,and the sinecure fs not intended or offered for sale(See.9044, -
BLLrmes,,ad P,ofa,rki,Cade:The Conaanors Liemko Law doer not apply to an Required Inspections
v $1000
-
r of properly Who huilds or Improves thereon,and who dirt.such work himself _
through hw awn employees.Interiors]that such Imm
preveaets are not intended o, -
ofloned for site If,towers,,the Indian,or imium,cntunn is sold within one year of
compDdon,Iheawnar-buildcr will have the burden nfpmvialidnt he did he build or 93��171 •��a.
i,np.ove fyr in,... if ealc). r u-1F, A. 00' .
❑1,as owner of the property,ant e.cluni,c],contracting with licensed emimo r.,u,
construct the project(see.7044,business add Prol—nor,CNe.)she Connector, 304 — ROUGH ELECTRICAL -
License Law does not apply to an owner of propeny who handles or Impl'oves thereon, i -
d who cortracts for such projects with o contraetoos) licensed pursuant to the
501. — FINAL ELECTRICAL. ENERGY
C hector`,Liemun Law. - -
atnexemptunderSee. B&PCtorhhis tenant - 505 '— FINAL ELECTRICAL
owner/L�� n:,hL >' /9•oJ
WO ZKER'S C PIiNSAT1ON F.CLARATIUN ,
I lietchyaffirch underpenifity cfe,ijudy one after,following d ha tions.
❑ l base and will nuairtaid a Cedifiesse of Can.e t to self- for Worker's
Cn ater,alican. a: isdrined f by section 3900 of the Labor Code, for hire ' a
performance ofthe work Corwhch this se t 1
❑i have and will muintuin Worker's Count,scion Insurance,as required by Section all
3700
3700 of the Labor Cade;for the plHonetunm of the work to,which this permit is
Issued.My Worker's Compensation]a.uence.carrier and Poh,y number ore:
Carrier To hey TIO 41
r „
CIiRTIFICATION OF E%GMPTION FROM WORKERS* h
COMPENSATION INSURANCE
('fits suite.need not be completed T Ire permit Is for ane hundred dolly.. A
n 1 nF m less.) .. I—
1 ready lher in he priftarmarceof he work'for whichmi,permit l sued I - -
shall a.,employ ay person y aname,ir so a,III Interim c subject le,Worker, •r.
`
Cranalk, arm Law,ifC lfrin, Date
Applicant
NOTICE TO APPLICANT
Apn0 after making this es n-' et of liscoun.,you should
Z .1acconnexubject In the Workers Compensation p sih d you nwa
0fano1no,ply Ihs p hl permit hill bed e 1i keJ.
p
p� ,
CONS 112 UCTION LENDING AGENCY ,
ai > I hneby aft lin that there Is a canrvuaum Ieadmg agency far the perfarmance
W of the work for which this permit is issued(See 3097,Or,C.) 1
S Q Lender's Name ,
z Lender'.,Address .. '
C.l 1 certify that 1 have read this application and state that the since Informatian Is
FL Fy cores.I agree to comply with all city and county ordinances and state laws relating
0 C.1 Inhuilding conscarrinn,and hereby annhno,e representative of this city he enter,upon -
,; W the ahnve-mcntianed property for inspection purposes.
y (We)agree I.,ins,indemnify and keep hannle,,the City of Cupertino ogni ash
p] liabilities,judgments,costs and expenses which may In any way account agohut said - -
C•) z City in c,msequenee of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLYWITH AT ON-POINT IssUedb �P ^( �V
$ougcaEcuLAnon I�P y: \ •Date'
sign/nature al Applm,InUcnnna r T—/ Date- Re-roofs
HAZARDOUS MATERIALS DISCLOSURE -
W,II too applicant or made building ,,,uptn,t stow n,handlefactories material Type of Roof
sidelined by the Caperton Municipal Code.Chapter 9.12,um1 the Heath and Safety
Cade,Seefon 25532(a)? - -
oroa 0N All roofs'shall be inspected prior-to any roofing material being installed.
Will tire upphcant mRnae Edging occupant nmalairydnt ordevfax which If a roof is installed without first obtainingan inspection, I agree to remove -
sundhazardous air contaminants asdefnedbythe.Bay Area Air Quality Management p g
' District' r all new materials for ins ection. Applicant understands and will comply with
❑Yes 11 No all,non-point source regulations.- PP P y
1 neo,Lae pro'ha,amous material,reyaireeeno order Chapter 5,95 of the -
Californio Haarh&Safety Code,SLetions25505,25532 eu125534.I unde...nd that
Cthe
Ibuilding Jnex oat cunemly have n mnon6 tint it in my restese,delity m notify the '
• oca,pana of the regnfrcnhend which must be met prlono Issuance of a Cmrdfi oto of -
Oerapancy -
' Signature of Applicant Date
Owner or authorized rgenl —�—D„ri All roof coverings to be Class `B”or'better