01030153 CITY OF CUPERTINO
BUILDING DIVISION. PERMIT CONTRACTOR INFORMA'T'ION:
BUILDING ADDRESS; PERMIT NO.
OWNEWS NAME. APPLICATION SUB DATE
FA n_
PHONE. SANITARY NO. u CONI ROL NO.
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BUILDING PERMIT INTO
Q ARCHI'1IiCf/IiN :1: : BLL ELECT PLUMB MIiCH
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LICENSED CONTRS DECLARATION Job Description
—W I hcherebyhherebyaBuT Thal 1 am licensedd under undar previsions of Chapter Y(collimatingf,:l-. with Section 9W()of Divi.+ion 3 of the Business and Profe,sonx Carl and my license
< i` n full rural and effect
icta CI.,'.� Q Lie « SGo r
ao u =-ZE=�r C....toonr
Y Dalc
at LL O e ARC to TECu a .,public
PION
1 undcnlmd my pl:ms shall tw u,nl u.public rccnN.+
ate Licensed PrWkasmmil �L /
u.ze OWNT:R.BUILD17R DECLARATION DOOR REPLACEMENT. ` G /
e _y I hereby affirm thus 1 no exempt loon the Ccnanactor'a License Law for the
C S following u.nn.(Section"Incl 5,Bmioc,n and 11m1'ev,iou,Cndc:Any 1.1your eaun y
D whin,requires a pernot n,ennstmet.alter.i,npmve,denoli.h,or repair any ntnclmre
a3as pr,or to its i...ance.allo rectors,he applicant lormcn permit in file asisned 4acanem
that he islicensed pn,..I ,,the prnvrumnxnfineCrammeme,LilcivcI-aw(Chaper9 Sq. Ft. Floor Area Valuation
(commencing with Section 700(I of Division 3 of the Bunincu and Pod..for,Crile)
or that he is exempt theater and the basis for the alleged exemption.Any violation
,itself 7031.5 by any applicant for u Islool nuhjeets Ilse applicant to a civil penally
of lncre than mel,mno-addoll—Wall. APN Number Occupancy'Type
❑1,m o..e,of the pmllit,,r my employees with vases va Meir sole compemaaon. .
%ill do the work,and the wuamrc is not intended or offered for sale(Sea.7(W.
Business and Profit vacre Cole:The Contractor's Liceme Law does and apply to an Required Inspections 88345
oner of prapeny Who hands or innpmves thereon,and who does such work himself
or thma,h his own empluyccs.P uvidcd that such it con,are not Intended nr
offtrAl rnr s:dc.IlL hn%�uvm,the building or iinprovemunt is sold within one year n1'
ioupletlon•the owncrholder will have the burden of proving Ilial ha did nal build to 35e,24017. 00
mprove for pupso+e of soled.
❑1,as owner of the Property.am exclmively contracting vim Ilcen+ed conmchnt,to
Ln.+vuct the project(Sec.vw4,Business and Pmre.+ ,n,Code:)The Connmator's - 515 — FINAL BUILDING
in hLuwdoetsbesuc m:n,owawh property whoh�liceori hercon.
and who t,;Live,fn, such pr,jcmn with a u,mrnaoq.) licensed rymuum n,Nc
01
Contractor',; Irv.
O 1 am ammpl under see. .B&P c Ruffin m:wm
. Owner Dam
WORKER'S COMPENSAI IDN DECLARATION
I hereby alBrnn under Penally of Perjury one of the following declaration,
❑ 1 have and will maintain a Cenificam of Consent to selLinsum for Worker's
Compensation, act provided for by Section 37M of the Lobar Coda, for the
performance of the work fin which this pennil Is issued.
O I have n 1,111 n,ai,nui„Worker'.Cni i,.,,aliun lnaranen,ac rcyulred by Section
3700 of the Irfor Cash.for the perfnrnnance of the work lin which this permil is
issued.Myy/JWn/rIts,,Compcnsaliun hotion roa,mi/c, ad�Polliicy numbs,are:
Carricr.Jj,L�U/' _Policy Nn.:f N/ ( S�63 /-t
-
CHR HITICATION OPEKEM1110 FROM WORKERS'
COMPIiNSAIIUN INSURANCE
1'1 hi, Oi.n need on be completed if the permit is Int one hundred dollar
0400)or Ica.)
I vanity that in the performance ohne work for which this permit is issued.1
,hall nut employ any pm'son in any manner so if,tu hcconm suhject b,the Worker,'
Compens din i lows nl Cdilbnur.Dale
Applicant .
NUI'ICH sol(1 ct it)
es after peaking this visio %of of Lidso io d you should
bcanmh coup y the Winkles pr Coinn%ortiun Prevision.of the Labor Cada You must
Q O
forthwith comply with mal lam-ision+anhii pem,it shall be AccmW rcvokcd,
CONSI UCfION LENDING AG I!NCY
I hcrchy i ffirnn that fore In a ou,lt old i lending agc,my rnr the purhammnev
W of the work lin which this pennil is issued(See.3097.Civ.C.)
L Q Lender',Name
D Z Laub,',Addrc+. ,
U Q 1certify than 1 have road his applientit and,tate tlmt the,hove information is
W.
P ,area,Ing,as ,,comely win,all city ttmI anunty orrllnan-,and state law,Maur,
Q
,_i
mhuildinge,n+wclion.tnd Marshy authorise reutsem:dl,l—I lhi.s Oly It,call,upon
y y me aM,vemlc
ealioaod pn, ny for inspection parlous.
L (NVe)agree to save.indemnify and keep liamdes.the City of Cupenino against
.F. W liahiliticn,judgments,con,and cxpcn+as which may in any way accuse against mid
U ti city in nmmqucnce of tM gmn0ng of anis Ix Co �✓�� �O
AI'I'LICANI'U D .COMPLY WITH ALLNON-YOINI' Issuedb Date J
sDuu,it b ?-2 g-�1. y'
art r, 'oalractm Dale Re-roots
c TIALARDOUS MATERIALS DPIIIOIURE
Will the aplifimnt fir future madding 9r apart core m hinds haraNa9,material Type of Roof
ns dented by me Cupertino Mpal Gilt•.,Chunrer 9.12.and the Health and Safety
Code,Scdiun 25532(a
oxen _ pyo All roofs shall be inspected prior to any roofing material being installed.
Will the applicmnor future ImIdat,occupant use c9uiponnt or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hanrdon.air eonwminuq. dchned by the Bay Area Air Quality Minagcmem
District?. all N all new materials for inspection. Applicant understands and will comply with
El ye, it all non-point source regulations.
I hator, lad the Inur.ardous nateriale na,iinameas miner Chapter 695 of the .
California Health&Sally Code.Sections 25505,25533 and 25574.1 enders and that
if the building dms not currently have a tenant.that it is my rasporofhility a)notify the
enpam oI the reruim, t.which must be mel prior to issuance of a Ceeilicare or
°talo"°s - Signature of Applicant Date
Z„r ahn,w.,,if, Date enc All roof coverings to be Class "B"or better
t
OFFICE