00120161 . CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING A DURESS: PERMfr NO.
1.6358 I IEMY CRUX PL 001.201. 1.
OWNER'S NAME: - ( • APPLICATION:SUB DATE
LAI, ERIC H A10 JULIA MtISTI 113./28/ 0110
PHONE: - SANITARY NO. - CONTROL NO,
�0Z0 ARCHITECI'IENGINEER:-' - - BUILDING PERMI"1'INFO
BLDG ELECT PLUMB MIiCH.
Z'
Z S,N Z LICENSED CONTRACTOR'S DECLARATION - 'Job Description
O —p Ihereby nfifimnhat l me licensed under provisions of Chapter 9(commencing
F twwith s i 1PUIIIofD i:rn 3ofthe Bu. dP f Ins Code,and my licen.ea
W W 5 .Liis a gc1 s w effect..
Lic.If ADI/I T roll•rlo R17zTICIDEL.
Contractor
co ARCfII'rBCT'S DI CLARATION
a, lunde.t J YPI shallMuseJ :pbfcma+Ns /� / - / y // // •" o,
O O L,ccr,cd Pod 1 1/f// (T,oV/�L /�/IJ, `/•/I!/
OWNI It 111111 DI N DI CI ARAI IUN
ut �` I h ny Idtion M1 he,l 1,r,ward hoon the C r t Li
t Z y ' - ft'yh
oil a (Section7031.5,Bu d professions CodM which mpe iup c r-Imo after, p demolish, yV
a.Fpct I t I: my rc II PPItf hpr ttId gn J�taencu
a ' �
liedhe it licenoolp -: tt,I lor p of Conn.(... Le5,
L Pt 1 - S FLFloorArea Valuation .
fen u m Ing w th Se i o 7000) f D 1 f the cine d P rcvk C� 12002 �• / -
or but he is exempt ih from and the basis for the alleged a prion.hfi n, J L - $7.,x1,1000
of Seetion 9011.5 byway applicant for a permit subsets ihu apphcunl am a civil......
arnot more than rnehundrddullt,($5t"n. .. AMU
APNNumber, Occupancy Type '
❑L'aeownen+l the prnperty.,nny cand.,ver with wages axrheir sole A >��e (0 r• i '
all do the work.and the_i s not intended or officied.f., I (Sec.JWi
Business and Professions Code The contn License Law does not apply to m Required Inspections
of pert Whohid prove.d and hod :such work himself ��p
'it II n bh h' fit ply ded 0 o h mr ren t. t vended or 1,01. — FUJhIDATIG1q
offered b"sole.IL however,me huildimg fir improvement i.c .to within one year of
iompletinn.the wnerhullde,will have the harden of pnrving that he did not Build or 10£3. F'IEIM3
mpm •-ar P e rf sole.). r .
103 LIFT.R
s Pe
it xlsvAY t gwilM1he tamrsm i
rum rl p ) C f5 9wJ 11 . 1 Poses Ins c A,)The c t soli t :1.04 .... FBiSdI-ll:
icon W a s not pule t r with
a pent'who is pct o thereon. ,
rid 1 e t to for n projects with a cormorants)hanKa pannant to the 1.fr AhIChIIIfi E101_.TS
—,
Comm�ao_Is License law. -
' ❑I ran a etnpt radar tine, .13 N!P C mr Ihh reasonJ '- �~::� � •
d.Of L:. ' AT'F:R'
Oncrimr -_Date %.03 - L1NDMM1,OMOOR N-UV111-0t1I3ING
f PR S GGMPEN9A'I1DN DFCLARAI'ION f�f�l3•,"• t B,rty-[C�l'fr•t(, rtt-•r•y-1fySl�rAt— '
1 by It i d I Iiy fp•Di rY one of me li 11 'nbJ n ' ss + P U'1,1DEs 00 IW..V N t-Y • •t
PO4 ' ' I.U�IDEId"I_.001F2 F`h'!N"�E: m
�t❑ I have d will maintain a Certificate of Consent to wif-iream, f r Workers ; •_ LIhQ7E151"'L.(U]I'2 Thi➢".A'iI(TN
G Cnmpsn mon. as provided Lir by Section 37W of the Labor Gale, for the -
,rrnrrnunce of me work for which this Permit is i...ed. - ,";301. "" hY]l.1Gl'1 f-9_tJhIItING
711 salve nml wed oudmalnWorker's Comprnnamnt montnce,as ne"nimd by Sect"'t 3(%J? - PL1Et F1. CJIti ::l I(]WF]i '
.tOdf of the labor Com,for the perfamorce•of the work Iia which mis permit Is -
issued.My Worker's Compensation himm car carrier and!Policy number are: c3f�13 F1'OUCIi'I MEC1-IRPIICAL
Carrier PolicyNo.: 3(d4 i•- FiOLI('il 117...1._(:TFt1CAl...
CERI'II9CA'I'ION p1'Ie%EMP'I ION FROM WORKERS s
COMPHNSATION INSURANCE 3ffK-; FRAVE:
. ohis secmnt need not becompleted if me petm6 is for nine hundred dauars 30C:, — HM.D(VNB3
(Sl(k)nr lees.) I '
3(117 , I1,1SUI_A•I•:1014
I cenify ihw in me perfunnnnce of the work for which this permit Is iesuN, "308 (;1HI' ,TTS 'i1y5
'
shall nm employ any Pennnen in any ria r so as to became subject to the Worker.' .
Compem.miom Laws of Califomia.Ime
Applicant 309 EXTERIOR LATH
NUr10E'r0 APPLICAN'IF IL film,makin"els Cenillene of Escrgain I.you ahold
become subjecuo the Workers Cuminnsation provisions of the Labor Code.You must 31(4"- .1.1sIT�.I'.'.LGI'l LATH
o 0 forthwith comply with such provisions or this ambilshall be deemed revoked. _
z g 311 — SCRATCH COAT
.r, M , • CoNSTRU(7LION LENDING AGENCY
C , I perch,amrnt mat mete i.n cli onomele Ila"asency for he pedrrmanee 31.3 :' F00F hIAIL.
'If work for which ori,Pcnnil it'issued(see.3097,Civ.c.) 501 = F'I:NAL IEL& RICAL EbUM dY
L Q a Lender',Name
z Leader'.Address M- 2 — FIIW. PL IE41IgG ENERGY
o I cenify that 1 base read od,apphcaion imd aIran Ihat the emfva inmonat)on is X03 FIhIN_ I IF'CI IAhIICAI_ ENE (iY '
correct.I ugocc to comply with all oily and county .swm uhhunnev,und ;as rebning ,
o to building construction,and hereby arwWrize mpresentatives at miscity umemerupan r• -
y W he K mentioned pm,n,for imp ti purposes. 504 " FINAL I UT.I..D,M3 ENERGY
Ea
A. (We)agotiose, do ly and keep hunt the City if Cummins, gains, 05 •— FIh1AL: 17-ECTRICAL.
tti h fah1i : 116 c,s b, I p :eswhichmay in any way accrue "amtsaid
C„) Cityitc m II sc nl tl "winkof mt. I t. s-, .. S)� P°
API11 \NTL lDBRSTANOS AND WILL COMPLY WRIT ALL ON INT J(JCI "" (JA.D TI:.:I T \�
5 I E( L IONS ISSu y: Date -
S"neon of AlId ctu nomel Date Re5O8fs— F I NAL..
IIAZARDOUS MATERIALS DISCLOSURE i
Will,me appliinunor No..Wildinkoceurvun slime or Handle houthrus material '►y tj6%XyT'RoWT7:hIAl._ GRADE
as defined by the Cupcnma Municipal Cole,Cramer 9.12,and the Realm and Safety
Grade,Section 25532m )? oNIm 51.0-r FIM.. F9._AMglhlfa .
All roofs shall be,inspected prior to any roofingmaterialbeing installed.
Will mnn
e appHeart or ma i,wlirmg oeenpant t,>eeyni,norm or devices which If a roof is installed Vithoutfrst obtaining an inspection, I agree to remove
emit hamNuus air contaminants as defined by the Buy Area Au,Quail"Xhur.,m
too
-
gi,nirn all new materials for inspection. Applicant understands and will comply with
El Yet 0 N
all non-point source regultilions.,
h'havc read the hu.,rmlo mammals rcgnircmems under Outpmr 6.95 of the
California Healed Fi Wre,Code,Sections 25505,'_5513 and 25534.I understand that
ifmchmidingdoe not cniremly have¢temam,that it is my mepoasihilitye notify the
car, or"fiber rants which mud,ba nidi prior lint issuance of a CeniOcme of
De , n ret --, _ A _ Signature of Applicant ., t ,Date ` . -
E ver, am cnmdit ent — Da�e'I All roof coverings to be Class"J3" or better.
OFFICE ".