00100177 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS. PERMIT NO.
10265 MIRA VISTA AV WEGNER CONSTRUCTION 001001.77
OWNER'S NAME: APPLICAIl(1N SUB DAPI?
44 1 ING SCOTT R 1069 CRAIG DRIVE 10/226/2000
PHONE: SANITARY NO. CONROI.NO.
(408) 252-22345
w c c AHCIIITECf/ENGINEIiR: BUILDING PERMIT INFO
BLDG ELECT PLUME MECH
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,6 1 CI I-1 I_1 I_I
py= I.ICENSEDCON'rRACIORS DECLARATION Job Description
1 hereby affirm that 1 am licensed under provisions or Chapter 9(commencing
's th Section 7(XX))of Oi oonlnfthe Btoinc—rol Prom—mi,CIA,.,film,license
n full mrce an feet,
'�z3 u.aOCit Licem—e sslate -, _ Lie.a am
—
DEMOLITION OF EXISTINGSFDWL
Date Care me - .n
ARCurniCIS DECLAR
I understand my plane.hall be use a,public omond,
dC p O 1-lanced 1'rofc,viina
ui OWNER-BUILDER r m the RATION-
s 1 hereby affirm that I i stem from the Ci on,C Any,Law for the
t a vshiah mu ivies. [Section 703 IS. and Prul'cneirnp CnJr:Any, or county
'<xp Which Its
xnpntmif recomma,aherat improve. Wmiti itrepair any statement
n3z prior ns issuance,aLw myuin•.a the applicant for such l,.Tminnlileanigned,tmcmetn
that be is waned raraantmthe pmvuimn.mrma cummaturs l.hene Low(Chapter 9 Sq. Ft. Floor Area Valuation
(commencing with Section 7oX))of Division 3 ol'the Ilusinens and Profesiom Code)
but he i,csemj,t themdinm am the basis for the at exemption.Any violation $15500'
od Section]IU 1,5 by any applicant for a scarf,objects lie applicnat ,,n cavil penally
of net more than live hundred dollars(S.500). A PN Number Occupancy Type
01.a,owner M the prorynr.many employees with wage%as ooh title c e:npeneatim, 797020:36, 0
will Ja the work,and me gmctum is nal imoNed or offered for sale(Sec.7(94.
Easiness and Pro6,%sions Code:*rw Contractor'.License Law does not apply to an Required Inspections
It Prulmrly Wim builds or Improves thereon,and who dos such work himself
or domigh his own employees,provided that such haprovemems are not intended or NO ASSIGNED INSPECTIONS
offered for talc.IL however,one building or improvement is sold within one year of
in,plctinn,me awnct,ouldt,will have the burd,o ul Proving that he did nit build or
mprove for pmr,ow of sale.).
❑Las owner if ore property,Int cxdnnivdY coana,mg with license sou neem i,
i f,tm,l the plica(Sec.711W,BnPnnte
inev,and ll..aC,O,,)'I jw Co:nra,or's
License
Lowdury not nacfapply fooff owner th acpocontraWho ctor )licenwImpmsum In'h,
ind who contracts for such projects with a amvacmr(q IianmA pununm In the
n ors Liars,
0 1 tem See
.aeacnnpt under See .If&1'C lire alis Dawn
Qwncr Dates Zf
WORKIiR'S CQMPENSATION DECLARATION
I or allirnn under penalty ,I caj.,one of the fullowimg deelumdnns:
❑ I havu mal will mabned n Certifiesc of 1700Contentof m tel Gina¢ for Worker's
Compenmtiin, he provider Ea by Sc mit 37(X) or mu Lohnr Gxle, G,r the
perfommnce or the send for which 0i,pemnif is issued. '
01 have and will muinmin Wake,',Comprnswlin Insulin,us requited by station �_-Z11 \ �11Z
37W of the Labor Cale.for the performance of me work for which this permit is
issued.My WorAcrs Cunt tion Imurancc curzicr nnJ Policy number nrc:
r er:5 ivD_Policy Nn:J_3LQQ7.S �vJ t
CHRIIFICAI ION OF EXEMPTION FROM WORKERS' _
COMPENSATION INSURANCE C .`
IDMS w0lon lived not be cungaeted il'the permit is for one hundred dollar U
ISI(Mor less.)
I certify that in the prli,nnm,c of the work rnr which this permit is red.1
shall nit employ any person in any mote',o)as m h"ou a subject i,me Workers'
Compensation Laws of California.hate
Apeirmt
NO'fIC,TO APPLICANT Il;ulttnoiking this Ccditicate rel Escnnption,you should.
hcotm subkd tome Worker,Cbmpenmtinn provisions oldie 1,1w,Cale,you must
Q O fumhwlm comply with Duch pr vimums or this permit shall Is,derided msakel.
Z
CONSRUsS10N LENDING AGENCY
1 botchy:itIDOI that Penn is u c urd(Sec
lending Co.C.) for the IsAmnancn
4 = of he wnN hurme whish mix permit is isnucd ISec.911)7. .C.)
IsnderS Naos
Q z Iq:Wd.e AJAnro
V Q 1 certify that 1 have revel this application and%tare that the above information is
W F.. earrem.I.igmv to cotany with all city and county ordinances and state laws mating
OC7 mbuildingestnranoonandbcrehy oval mis city,(inter spa
fa: diW e alawc-memiinpmpeny for inspectionry
purxs. t
F as (Wel agrc• 'ndemnify and keep harnlcsn the City of Cupertino against
V]JAPPLICAN'
liabilitien,Jw alms ro am xpc cs which may In any wary aeons ugulnst.aniA
U ZCity in can tore the PPein pe ni
L DS:.UK'II OMPLYWITHALLNONI'f11NT Issued by: �� Date
SOURC' Al Ilt S. ! Y'
.ignamre of A,duantl/ amractm Oats Y RC-roofs
IIA%/cat DOUS NIAI'ERIALS DISCLOSURE
Will the applicant or future Wilding ieeupant store or handle lim:wnnt,material Type of Roof
as deEacd by one Cupertino Municipal Code,Chapter 9.12,and the Icahn and Safety
Coda Section 25532(H)?
SY°a 711;"i All roofs shall be inspected prior to any rooting material being installed
Will file dmhl ant orrnoebnudlegoeeapmttuse ri,apacme,divlenwhirl, If a roof is installed without first obtaining an inspection, 1 agree to remove
an Woodcuts air commnninams as ddined by the Bay Arca Air Quality Managenun
,strict? all new materials for inspection. Applicant understands and will comply with
Ove.'
FV No all non-point source regulations.
I have read the lmr na i c,nutmials requirements under Chapter 6,95 of the
Culllinniu llswlm 'Dry C'odc,s elion,2550.5,2553)wW 25534.l anden,,anA that
if tlrc M:ildin ov arenint.mat it i,my rcsp:msihilitymnnlify lite
urapam t nes � n na,t Is ten noir m i,.aana ora certiEe-an or
aanan rzn/, '
Signature of Applicant Date
aammri.w„gen, nidi All roof coverings to be Class "B"or better
OFFICE