01060018 CITY OF CUPERTINO '
BUILDING DIVISION PERMIT 'CONTRACTOR INFORMATION-
BUILDING ADDRESS: PERMIT NO.
"AM APPLICATION SUB DATE
• 1 A N CONrROL NO.
C zARCHITEC77ENGINEER:
BUB.DW RMIT INFO
w O
(AE)H 406 9725
z 6
_ BLDG BLE PLUMB MECH
,,a= r.— C IJ C-A
08='z LICENSED CONTRACTOR'S DECLARATION g �->:���fobDescription
I hereby 0)or Division
l am cuselicensed under and
Profs Profession,
ser.(costm¢ncia
Q—mFLI is in Section 7000)andefcat. nnJOFJIe BYSN<Ss Ind Pfnl[Sxlolli COd<.and ylicense -�
y E is in full torte and<Bca
X02 xcl — fl Lio..�� INSTALL SUB PANEL/
w C vapor r
F,u,O ARCNITECr'S DECLAR ON t
�� Iundcrsundmyphnsshallbeuxdspublicrecord + A/C CIRCUIT.
a po Licensed Professional /�7
k Oat I am exempt( DECLARATION
1 hereby affirm than 1 am exempt from the Contractors Littnx Law for the
following reason.(Section 7031.3,Business and Professions Code:Any city re county
ne ne-C which requires a permit to construct,alter.improve,demolish,or repair any structure s
i 3 Or prior to its tauaneet al Ne Imam for such rmii to f l _ _____
try PP P< gawdsuscmeno.
that hevhcenscd Norman'd Nepo tssons of J:e Conmacm' CertseV lenapar. S FLFIoor Area ,
mammee is exehsecma 7moand tebasinaanneligixd aand666.As - .9,� .?.: �,J l.lalrlN' Valuation
or that io is 31 j b nc�rcfrom and me basis for the als the aempuo o Any violation
of Section]Ol I$by any applicam for a permit subjects me applicant m a civil Penalty
of net mare them five hundred dollar,s5 W). APN Number cupancy Type
❑1,ne owner of the propcny,Or my employes with wages as their sole c tmpcns.m...
will-do the'work,and the'suvnure is not intended or offeredFar said ]OGa,
Busitiass and Professions Code:The Contractor's License law does not apply to an Required Inspections "
Owner f property Wb builds o improves thereon,and who does such work himself •'
_.m through his Own amplaYtes.provided that such improvements arc not intended or
offered for sale,if however. be buildmi or improvement a sold ma- - e ye;or - 3 04 — ROUGH 'ELECTRICAL.;;'-
'complet on,the owner-builder will have the burden of Proving that he did not build or c
improve for purpose ofsale). 501 — FINAL ELECTRICAL ENERGY
r contracting - ---- -'505 = FINAL' ELECTRICAL--'---- --------- '
L.u consuntowner of Ne .._.-.....,..---_--
- c propenY,am exclusivd cpnvunin th licensW coovacmrsro
License
the project(Sec,appl]Was Business and Professions Galea The Contractorsreon.
-- License Law dines not apply to pan owner of aPontatinYcomm who builds or improves thereon.
the
_and-who raLice se Law. projects wilt a convanogx)licenxd.pursuvn to the. ._ ._.. . __..._.._ ._...
Contractor s License L
❑laexemptundersa - "' ' 'd ,B&PCfor this reason �������®
Ox Dem, - _ .
WORKER'S COMPENSATION DECLARATION
Imodo nn - .. . - - - APR 2 9 2002
.,, y. Penalty of perjury one of the following declarations:-
❑ I have awill maintain a Ccnificum at Consent on self-insure for Worker's
ComPcmmbon.-m-provided for by-Saban 3700 of the Labor Code, for. the BUILDING
"arm.
of the work for which this,permit is issued .
ave and will mainuI Wooler',Compensation Insurance,as required by Section
3700 of the labor Cade.for me perfor.wnc<of the'work for which Nis permit is
issued Wmrkds Compensation Insurance carrier and Poli
:.a 1_' Orke,r. Penn -_ Policy number are:
Corsi, 461i[Y No.:�ll Y-ai �� -��
..'i%:CERTIFIGTION OF %EMPTION FRO-WILWK S'C' �.Ux:'• T• .•`;>�y t^'m; :'ti'PA7%'is1
L.COMPE. ATION,INSURANCE;.
It
(This secriori need not be competed of the permit is fare"hundred dollars - '•''s ' : 1-i..�;, •'
(S too)or lssJ
,',,•.I
terrify that in In,perrormancc sm Na as to b which this ct to t e issued,1 .1, """-"R`-" -'-• •-�-r.^ -_--
shall not employ any'Prison in any manner so as m become subject to the Workers'Compensation...La. of California.Date' s
--APP,am _._. ... - ._- . ._.
NOTICE to APPLICANT WrrkB COMPOnsaLiOner making C<n,tate fExabor -- -------
be subject ro the W ke! Com t o' n You should
'� 1 pens p ons of N e ne Cole.you must
fonh In comply with <h provisions or thispermit shall be deemed revoked,
" 'CONSTRUCTION LENDING AGENCY
�' Ihercb firm thatconstruction lent
_ya r Yagencygfortheperformance Ir
W,r of Len work for thspertn Ys issued Sea 109] C'v.C) -' -
tl .
y C des Name ..
Z Lender's Address .. ._- : - ._ ..,. .......... ...._ .�... .. ..__.....--._-_._.--_ __ ..__...
r
V'� 1 ri fY Jia 1 h read m aPPli t d i m Nm m b 'nformanon v -
QFT+ Fo cored 1 agree[a comply with all city and county ordinances nd state laws rclim ng
'O to burildingconstruction.and hereby authorizeeprse ti x ofthis city to enter upon "
�s C.1 the above tranocird property fr'nsp ni p tpose
G.! (W)agree t dm 'fy
h 'dk ph 1 "IsofC pen no againu
Z uy, ot/\`AJC,/✓l,\/I
Cty,in a dg t d pensee h h y n any y against said
U n equanct. coe of the Starting g of this
permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH` . . ALL NON PovrSOORCEREGUEATfOhs
Issued y ,) ✓CL Date �r
Signature ofAPPlmanJConvaaor " "' " Date y, Re-COOP$
a HAZ kRDOUS MATERIALS DISCLOSURE
Will d: pplicanto future bulding pant=< Or hmdljhazvd ,material T eof Roof--
viol r d do Cupertino n MI n c p I Cod Chaps .I and theHealth and s f ty yp -
a' Section 55]1111 r - "" i - -
❑Y ' I'_ '_tr It l t . - , 4 /. ',err `(..I e j Il J'•,: ... , I
'- roofs shall.be inspected prior-.to.any.roofing material being installed.,------ _
W IIN -pylic tbar ldingby p Ali.
Art Quality Managemcm p aortic e,wmeb If a roof is installed without first obtaining an inspection J auree.to-iemove
. m
t hads contaminants
dcf�by tbe
AArea -
Dist a �
pye - El No ,_all new,materials.for.inspection.._Applicant understands and will comply with..
all non-point source regulations:_
I ha a read die hromi. - material.rcgmmmenu under Chapter 6.95 of the - t• -' "
Cul roma Halth&Safety Code Sections 25505.25533 and 25511:I understand that _
if the building docs nor cum have a tenant that it is res -"
tw Y pnceoia sonority the
occupam ar Ner � �� --
rcm ma poor m,.amntt of Cerdfcate of '
w
.-- aeananr.. . .
-. ...
-_Signa[ure
.ofApplican[._ -.-. .. .. .__-.I . .. Date
Ow ero -milbnaeda am
-•;. /. g` Date All roof coverings to be Class"B"or better '
._...OFFICE" - - -- -- . .
-