00120126OFFICE
CITY OF CUPERTINO
CONTRACTOR INFORMATION:
BUILDING DIVISION' PERMIT
BUILDING ADDRESS.
PER 0Nvj :?- 26
OWNER'S NAME:
APPLICnl'ION SIM U6rli
PHONE: 1.974'9 MERRITT DR
SANITARY """CO ROI. NO.
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ARCHITECT/f'{1I I13,�AR
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BLDG HI.Fi PI IM1 MECH
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LICENSED DECLARATION
ONoval
Job Description
under apter
1 hcnby vairm thm lam IiccnuW under rrovi.ints ng
Iant license
i ro Code and
with 7(NNt Division] of the Bu,iso, and Pntl'cn,ions GWc,und myliccnw
of
Lb full I." v. and elfcct.
lot]
imens C6v, Li0.M
Dntc
e
—
SDECelo,
OECLARATIoN
ARLIiall
<
J
he used
1 unJcr,tnnJ n,y Plant .hull M1c u.aJ a. Public mroNs
ADD GAS CONNECI TON
Lw..wd rroms.i.... A
OWNER-BUILDVR DECLARATION
T
I wFeby ufbnn Ihut I an, ascn,pt front the Contractor's Licenec Luw 1'ordnc
following reason. (Section 703 I.S. Buame.v and Professions Core: Any city or c6unty
which requires a permit h) construct, cher, improve, demolish or repair any structure
-
-
pnor no, ksuan,e.al. 1 tlie of I - bl it 'b d o.nauetd
that he 1 sed! No,nani to the p I the Contractor :l I Chapter 9
Sy. Ft. Floor Area
Valuatiofb 6 .
(comm g with Sectio 700(l) of U i 1 to B d P f Code)
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or that he . p thc,Jroni and the hall, Ion the all,nd cxe ,, m,. Any violation
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of section 70mo316 by any upplicant 10, t penny ..bpa," etc arrlicam n, a coil renNdy
APN Nu er
Occupancy Type
01 not morsdito live hundred dollar, WN 1.
❑ I, a, owner of the nropemy, or my emplovecs with w,tgo a, their ode eungw,nmion,
Required Inspections ; 10010
wdl do nue work. and the o,om.m i, nod intended ,, offered for ,We (sec 7044.
Bus;oe s and rode,.ion., n.le: The Cmuacto;. Lieanm Law does tot apply to un
r of pn, ,ny who wad, or hupowe, d i,eon, and who doe, ,.ch wo,k hhn,eR
or through his own employee,, provided that such impro,e',wnt' arc ant intended or
proveent is sold within one year of
oRered forMade. 1f, n.,e,er, thholding ading or imm
3163501 0, 00
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the rw,nenwilder will base nue burden of,ro. t, eat ho did on, built]m
nnnpletim,,
npm,e for pu, wv aINWeJ.
of thedu , l c....L r sow, ilh wt,o
o,,Seediia,it4. cootrr1io.1)
202 --- UNDERFLOOR PLUMBING
colvue�wner the ject Codicil Iwd
dd, ;mpro,e, there,.
.Law d,w,,tap,lyloan nwnvlof p,ol„•ny who wm
Liecmm
301. — ROUGH Pt I.IMBING
and .,dcen,a or such Pm ecu will, a o.weo,s,) Iwe... it pursuant to the
C
502 — FINAL PLUMBING Eh1ERGY
mtmhu
0lame.emt,lmlersce. B&PClmthis mas„t
506 — GAS TEST
Owner\y,f)RK12k'SC'ONPLNSn'1'IONUECLnRA'rION
507 — FINAL PLUMBING
I hereby affirm under penalty of pt jury ane of the following declarations:
L sit 'tut. d L CMar i t Workere
yr
❑ 1 1 I II a t' .u,
t
mPv Jed 1 Seca f the Lrlro Code. lin the
Cnpe : t . m
parfo )I the ,d 1or ,ufll J.
❑1have d wilt mi Worker , Corn,liwaLion Insurance.'rey dh)Section
2�
ur Curie, lot the rr,rn once ill the work for which this Iwoun is
37W f the Lubpe
o
issued. My %V set, Cnnpcnvainn In,uruuce curio urd Policy nundwr are
/
Cmrlcn Pobcy No.:
Q
CHWI'IFICAT[ON OF E%IGIPI ION FROM WORKERS'
COMPENSATION INSURANCE
'
(Otis n'ctinn trod nut he en r,loi d if the pcnniI i, for one hundred Jnll.n
151W) nr less.)
I uendy that in the ,It col 'the work In, which This wonu is issued I
,hall not employ any relmn in anv manner wl us in lacunae '.hire' m the worl.al
CmnPenmline l.a—ot Cubfornia. Date
Applicant
NMIC12 TO APPLICANT: it. ager making thio Ccndk.te of Exemption, y.a should
L
hecnmuenbjccnn the Worker', ComFn,atlon pro,kion,of the labor Cottle, you must
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lonhwith comply with such provisions or his permit %hull be Jcnmul revoked.
CONSTRUCTION LEN DI NG AGENCY
I hereby anion thin there is a consunuo n lending agency lin the paoro cwu
of the work lin which this Demon i, issued (Sec. 3097, Civ. C.)
Lender's Name
7
l.cndd, Address
rilyll llh Ido -Ill 't Jttre,of Mo. i'! s
IJ
.1 II ty J yfoaulcl Jt t lb t ,g
nm'tF (1) comply t
c,
In buildingc strut dl, by dl, P ti fah cryo t put
.zl
the' b t J Pno,cry t ItT
y
(N) agree to voe., ly J keep I s: II City I L I d & ba
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uwnh may n any .) anrm ago n.t atJ
- ja,ucn,,, ....... nd a,p,nw ,,
Coy i
APPLICANT UNDER til. ginning D his Pc mut.
APPLICANT UNDERSTANDS AND WILL COMPLY WITII ALL NONM)IN'1'
/^� /n� 4% Y C�C!
Issued Idyl sL ��:.//t��Uk--Lk Dale
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O�OCon
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Re -roofs
..gtmumnrnpN;eant/a,ntmelnr Dale
r000r
HA7Aku0U5 MATERIALS DISCLOSURE
Will thu mnc nr nuctvfland
orMfuture building Co
Type of Roof
c Cul,am
e, Chaln and thehm Health Sakty
by A Copenino Municipal Cale, Cwp¢r 4.12, unJ the Ilcallb unJ Safety
d,,
5
Cmlc, Section 25SJ21u1' /
C Ser
r] Y's
All fool's shall be inspected prior to any rooting material being installed.
wet lie appB<om orfm.m nodding rwc.pam use ey.lpmmn o, mein' which
If a roof is installed without first obtaining an inspection, I agree to remove
cam h:va don, tar enntamin„til, u, d0owd ny me. Buy Ao a sir u.a1u, Mun.1nu,ot
Dwrim?
all new materials for inspection. Applicant understands and will comply with
M
❑ Ye•. -F/
all non -point source regulations.
I have read the hemnlous mmcrials nei o e nems under Chapter 695 .f the
CnliR,m;a Health &Safety Cole. Sections 25505, 25533 and 25534. 1 understand that
if the IN Win, dwro not cumney havuuenun6ohm it is it, rs„00nihi lily u, notify the
,
occupant of the requirements which must he Incl prior n, is.suanec of a Ceniticmc of
para°'
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Signature of Applicant Date
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�` �� d a, ” ������
All roof coverings to be Class dB'r or better
lir or audhurized agent Omc
OFFICE