00070166 CITY OF CUPERTINO
1iILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BU H.DING ADDRESS: PERSInNO,
OWNER'S N4.ML4350 MENHART USFF- nprl.Icnn
515
'IIrt sl:: MCINTOSH snNITn1IY. I cwt ..
C Z ARCHD ECIENGINEER: BUILDING PERMIT INFO
FOgqO - BLDG ELECT PLUMB MECH
yad
a hI I lion I a ,ficenled and R'S UECLn It CluiN Job DCSfa'Ip11011
z S= hereby(flhm Ihul I oat Gcene B under nrnaI'l lC m Cs Code,all
Iincnse
rntw with 1.11 fore and of Divi' nJuf,h,Otssinessand l•rofnslun,Cod Jnry incense
<a,P J is In lull force and eff yr}��
x z s 2 License Class Lic.p �./7•J(T/'�
o U Date cnmmctm TEMP POWER
5 3 u v ARC E 'S DECLARA'1'1(lN
u 0 5 1 atone�w J �r d as pabl' ds
E r f` '��
+�+n O O n„d Pmt ' mal
OWNHR-BUILDER IlECLAItA1'ION
ed�^— I hereby ufllrm that am oxetnp,fnn,the Councillor's Licence Law lin the
1'nllowing r,awn.(Section 71131.5.Resines and 11 ..inns Code:Any city nr county
E S o which require,o permit II.....tunt,alter,itnpmve,demolish,or repair any mntcuvo
i3� prim In its issuance.alw requires the applicant for.such pronto file a.signed aemntent
that he isfiee.,edpersonmtnthe pensiten,of the Con�actnrsuanseLaw lch:Imery Sq. Ft. Floor Area Valuation
(commencing with Section 7000)of Division J of the Business and Professions Cold
Ili that he is exempt therefrom and the breis for the alleged exemption.Any viulaion
of Section 7031.5 by any applicant for a permit sadism the applicant to a civil penalty
of not turn,than five hundred dollar,(5500). APN Number Occupancy pe
El 1,anovine,ol he pmpnty.mnryempinyecs with wagssus their sol,cI I,dnsminn.
will of,the work,and the strncmre is tut intcnncJ no ol'I'pcJ it sal,(sec.7144.
Irion,.e.nd Profession.Cod,i Contractor',ueen.e Law noel m„applyy ,nit 3751.6016., (Wquired Inspections
r of property Whit builds..t improves thereon,and who dines such work hinsoll'
or through his well employees.provided that.such itnprmoenmms are not intended on
offered for sale:If,however,the building or imprnacntent is sold within one year of
completion.the owner-M1uilsMr will have me bodcnof provingthat he did not build or 103 — UFER
Improve far
Pum,eofello). 304 — ROUGH ELECTRICAL
01,as owner of the pulwrty.am exclusively°nulling with licensed contractors nt
.stun he prier,(see 7044.IW. s ml propelCoda.)The Comment',
je c Law doe.nm simply to un owner of pmper,y who build.or improves thereon. .
and who comma,for such PomCoN worn a.onwann.).licensed panuunt to the
Canna uor'e License Law.
01 am exempt under tied. 13&P C Ibr this coaxon
Owner m
WORKER'S COMPENSATION DECLARATION
1 hereby affirm tinder Penally of CUm,otic of the following declarations:
p1 have and will muimain a Cenificam of Consent to self-iawee nor Workers
mtpensatlon, uid
, pmved nor by Sell.... 3700 of ma Lxhnr Cale, for the
rerhmnance of the work in which Ibis aroil is issueJ. -
01 have and will maintain Worker's Comrymution Insurance,as required by Section
3711 of the Labs Code,for the performance..f the wed for which this period,is
issued.M>'WaJ�1 C/,CCoomppons/mni'a,a Insurance carrier and Policy number am;
Cavi /f "r �-r!/'/if'sYicy No.:'
CIiRTIPICATI NOP F,%Eb1PTION'I'Rl1M WC KERS' -
COMPENSATION INSURANCE
(This section n,od in he aounp old n in,nonoil is or one han fired dolluts
($100)nr I....)
I Certify W:t in the pemi...mine of,he work for which this permit is i.oudid.I ,
shall not employ any person in any manner Io as In become subject to the Workers'
Compensation laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenificme of Exemption.)ora should
become mbpe,,m the Worker,Compensatic.Noevoons of the probe,Code,You no.,,Q fimhwhh comply is th.such provisions or this permit shall he deemed revoked.
E' G,NS'I'RUCI'ION LII
ENING nGIiICY '
CC , I hetchy uvpro that there is u"horn.ctlon lending Igor,for the peofo..nun,
of tire work for which,Itis pennon is i...Cd(See 3097,Civ.C.) _
d Q Lenders Name
7 7 Lender's Address
V I certify that 1 hove read this applieni.n and ,are that,he above information is
tas E” correct.I agree to comply with all city and county nrdinum'ea and stale laws relating
Q V an building ennometlon,and hereh)'aathorite representatives ofthis city it)enter upon
the above.tncnaaned pmpeny for m,peor to namove,.
(W,)ngre,pnvave,indenmify and keep hornless the city of capcmer)ityain,t
F. Z) fin tolai,s,jadgm,ms.....I,and exper e,wild,'tiny in arty luny alone agaiosl ruin lY
City in consou,nonceol he
APPLICANT
GUDRSTANDS AND WILL COMPLY WITH ALL NON-P^Ni Issued by: Date ^ OD
St LA
natureI, ApplicmtVC, or.. ate Re-roofs
I IAZARDOUS MATERIAE S DISCLOSURE
Will the applicant m for..Wilding..pact score m handle hamrdon,n,a„dal Type of Roof
or,defined I,y the Cupertino Municipal Cotte.Chapter 9.12,and the Health and Safety
Calc,JC,ti,;.25532(a)'! O No
0 Yes All roofs shall be inspected prior to any roofing material being installed.
Will the applicant of Prince building matgaln ova ctlaipmere cr devices which If a roof is installed without first obtaining an inspection. I agree to remove
emit hazardous air conmm...tu c,as deficed by the Illy Area All Quality Ma.xgement
District? ❑rvn all new materials for inspection. Applicant understands and will comply with
0 yes so all Port source regulations.
I have read the Injunctions materials requirement%under Chapter 6.95 of the
Culifomin Health&safety Carle,Sections 25505,25533 and 25534.1 understand that
If the building does not Currently have it own,,that it i,it,ne,,na ibillty at no,iry the
oecepan(of the rcquircnmms which meq be otet prior to issuance of a Cen.Bcute of
Signature of Applicant Date
Ain't.
aud,..da
loosen llDumAll roof coverings to be Class tB" or better
Ain't.
OFFICE