00120159 CITY,dweciv ONO
BUILDING SSINPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMI"f NO, -
12161.8 R-T.NTSHIRF_' ST JUST Wn'l i I-IE:nTERS 11,110 0011 0:1.59
OWNER'S NAME: APPLICATION SUB DATE
f� PHONE. I'1(JITi'.SON.Fi'C)Ed:]"iT n (114D Sl1—VIP P ],%64 blf)T1011 t.. AVE 121S P.00 NO. CONTROL NO.
NITARY
(x:1.0)1:29.3. 1.3"X4:1,
O OARCI I I'I'EC17ENGINEER: BUILDING PERMIT INFO
xzC BLDG ELECT PLUMB MECH
y6d CI [J —I 1=J
Z ti - hereby athlCEN4Fp CON'1'RACE URunder IS DECLARATION
ChN 9(amme(commenting
fob Description
���+= with Section 7010)of Division 3 DheSt ndPafex,i CJ lmylicense -
¢X S 6 s er ee recce and effect. RET--9—n[Ir 40 GALLON GnS Wn•IER KDUE R .
0.r,K 6 L cense Coral Lm.p
X 0 V Date Contractor. . .•
S,O ARCHITECT'S DECLARATION
[S,N 1 understand my pleas Shull be coed as public records
S p O Liun.ad Professional -
:J o OWNER-BUILDER DECLARATION -
no, 1 hereby affirm that I ani seeing from the Comranorh❑crow Law for the
foll b .(Sect 703 1 5 B : d 1 f .Calc Air,c Iy urunnly
I F G
'h 1 ti .an t t.Ane,balance,demolish.or repair any structure
c�
prior to its issuance,aloi1 the applicant f such pe 'n 11 signed nteme t -
3_ thiol l Ip l tti p' conx_ leshe Contrat1" L (Clar9 Sq. Ft. Floor Area Valuation
(ct same ae tg with Seceon 9000)of biv e cn J of the BuC tees and Pmf ss'ons Cteode) ��L�� t
or pmwW
t he Is exempt therefrom the hassis for the alleged exemption,Any violation
of Section 7031.5 by any applicant fora permit subjects the applicanum a civil penalty
of not more man five hundred dollars 1s500) efAxPNNumber Occupancy Type
01,as owner of the property,or my employees with wages as their sole compensation, 3)E'2a,%02.00
will do the A d the structuret intended IY d Far sale(S 7041, a
Ba I Profiesilon,,Cal .I he Contractor's LiAnou Law d t apply a,an Required Inspections
fp 1 Iy WI h Id. Ih t d h 1 1 kounwIf r.-�7
:,fi ,ugh has owa,en p1 yea,.prmvii that nth improvements are amt aended or .700._ — F Ibinl._ 1=L.111 R1.1''NG ET�SiGY
offered conal,.If,however,the building or improvement is vole within one Year or triC)EY -• I:in.S TT•:iT .
bmplepon,theowner-bander win have the burden of proving that he did not build or - -
impmveforpinposemisale). `.,H7 — F.CN(U._ PILL111BING . .
❑1,as mwnermf the propcny,am exclusively contracting with lieenmd contractors to _
an I hmif L uchP tri with u-r rk) itd pursuant to dho
CoI I I' nseinnI Iteproject(5 7 B aJIf ons'ed,:)Th C lem
License Law
appyloan
r fp pImbn improve,thr,
_
❑1 am exempt c, R&PC for this naso
Owner nal El
WOR
WORKER SCOMI F:NSAIION DECLARATION /
I avacity affina under penalty ltYIII'p j y one ofthe following declarations:
_
al 1 have and Isill anumnan . Ce uncal f Consent to leduman, Car Workers
compensation as provided for by Section 3700 of the Labor Cow, for the -
permm
rance of the work for which this permit is issued. _ -
❑I have and will maintain Weakei s Conipenevtion Insurance,as required by Section
3700 of the Labor Code,far the performance if the work Iia which this permit is -
ssucd.My Worker,Compensation Insurance Innis,and Policy number are: -
Carrier'. Pokey Nn; - +
CERTIFICAI ION OF EXEMPTION FROM WORKERS'
COM .,
1 COMPENSATION INSURANCE '
(This semina aced not be cenapleted illhe permit i,iia no hundred dollars s
(1100)or lac,.)
1 cattily that in the performance of the work for which his permit is issued,I
shall not employ any person in any manner so as to hiecom subject to the Workers'
Compensation Laws of California.Date
Appbc am
NOTICE TO APPLICANT:It,alter making this Cenineate of Exemption,you should
become subject to the Worker',Cnmleb ation.......ions ml the Labor Cni you must
Q Q
but hisith cvmply with such novisin,fir Ibis pi shall be deemed revoked.
z
CONSTRUCTION LENDING AGENCY
Iheathy affirm W that @ereiss and auction leading agency for the perfonnanma 'of the work for which this permit is issuedissued(S(Sec.3097,Cis.C.)
ra
❑ Lender's Name
5z Lenders Address
L.1 � 1 ' rtfy that I have readthis ppliat d state that the abovef tionis -
ty
comeat.I'l to comply oult all cityanl county ormarnAssandsame la ( ling
Q (�
to building consinctingandM1 by anthorize representatives of itis city it)cramupon
�] the above-mmntianed progeny for inspection purposes.
�.t its (Wel close to Ince,indanmlfy and keep harmless the Cilymf C,wrtmo against
L V1 Iittahtic,,judgments,cuts and expeneex which any in any ,by amme mains,said - r
V City in consequence of the granting affix permit. - - -
APPLICANTUNDERSTANDSANDWILLCOMPLYWITHALLNON-POINT Issuedb
SOURCE REGULATIONS. y: ' Date '
Simatul'anf AppllcunnCmu'art Dine Re-roofs -
HAZARDOUS MATERIALSDISCLOSURE -
Will the applicant or Ratio,madding oenpam sum of handle o-aaaalou,material Type of Roof
as dc0ncd by the Cupertino Municipal Code,Chapter,1).12.and the Hernia and Safety Cede,Seetion 25532(a)P I
❑Ye, 0 N All roofs shall be inspected prior to any roofing material being installed,
Wi l is npp0eont or mare bdlding ouupnal use cyairmam or amvimr,when If a roof is installed without first obtaining an inspection, I agree to remove
emit meardom air mntmnlnants a,defined by the tiny Area Air Quality Management
Di,triettn ❑No _ all new materials for inspection. Applicant understands and will comply with
C?Yew all non-point source regulations.
I first, end the haeunlous materials requirements under Chapter 6,95 of the
Californ'm Health&Safety Code,Sort.-255(15.25533 and 25533.1 undersand that -
ifthebandingdoesnotemrentlyhavea emmt,that it 11 my rmspar,mility in notify the '
occupant of the requinmmats which must be mat prior m issuance of a Cenifieam of
Occupancy. - .
Signature of Applicant - �� Date
owner or andmtire agent Dale All roof coverings to be Class "B" or better '
OFFICE