00110103 CITY BUILDING DIVISION
NPERMIT CONTRACTOR INFORMATION:
BUILDINGAIq)@f$�5:17 MIRA VISTA AV CLOUGH DAVID B AND hI�MSA001101.03
OWNER'S NAME
O: AI'pue,tinON SUB DATP
CLOUGH DAVID B AND ANNAL SA 1I./ _C40
PHONE: SAN]FARY NO. CON'tRol,NO.
Q=Z ARCHITECT/ENGINEER: NUILUING PENMI'I INFO
qq BLDG , LEC PLUMB MIiCH
LICENSIlDCIIN'IRAmON'S UIiCLA NP.Chapt Job Description
ZO =0 thereby Af of that1amcf1deNumler previsions of CM1upmr9(commencing
<a,t—w witnsearon7aro)onrbisinn:�nrine.un.ineF.andPrnra\.Innnc"ne.anAlnyran.e ELECT UPGRADE
'^ is in fou force and?Ran. ,
.d< I.iccnm Clm, Lic,a
O,w U:nc Conmwmr
ARCIII'HICI"S DLCLARArION
Ca O g 1 understand my plmo,hull IS,ams!as public recited,
of Y �/
i C O Licensed Pruhssianal c _
OWrNL'R cle LDI-ro DECLARATION
I hereby arborsthus 1 um e�emrt from the Cnn,mnnr'x Licence Law fur the
F Z a following reason.(Section 7031.5.Business and Pmfettions Code:Any city or couny
r1 O which ntryimx a permit m combust,aher,improve.denmlinh.nr repair m,4.so...or,
prior o its issuance.atmrequire,the applicant list such penniva Cite a signed,lamment
—
that he is licensed pai>wcmto the postmons onhe Commctort License Law(Chapter 9 Sq. Ft. Floor Area VitalNO
(inn usemang with Section 700()),d Dicki i 3 of he Bamacss and Pref-ions Code) G
or that he is exempt merchant and the basis for the alleged exemption.Any violation
of Siouan 7031.5 by;my applicant fur a lanni,.arbjenn he applicant to o civil penally
of ant more man rive hundred dm0nn(9500). APN Number Occupancy Type
ol.asowNoofthe,aoxi, to whhwae%asTheirsolmn.n,aameone, 5702039. 00
t I -Y.onnyeisp ) wag
e%
do he Wind.ani the ode *O C nm amended or neem,for.ole(Sec. or an
Business and i,riy Win)
h Code *Ow iso, n,,o ,andLicense Law isms not apply.an Required Inspections
ovvm,,cf his ow whit naim.mivided thatuch.mpr It,,does
arcntt intnied In 304 — ROUGH ELECTRICAL
or through mat oma an eves, it,
provided slim such improvements is sol are not intended or
offered to,t:ire.fl:ho,builder willaveonerundcoo ,m%i„oatliecmonenldor 501 — FIMAL ELECTRICAL ENERGY
completion.the ow ob llder will have one buNmn nl proving that he dIA not build or
nnpmve for raq.,,c or,ale.7. 505 — FINAL ELECTRICAL
0 L a,uwmer onhe rmpeny..,,I exclusive,camranir,with licensed contractor,m .
,nstruct the.ymjea(See 7044.Business and Proressiom Cmlaam
' e Contractor',
License Luw des ren apply ,,an aware at pn,,city who beild,or improvers,hcrcun.
and who comma:for much pmjmrt with a contractor(s)licensed Pursuant to the
Commctor's License I.uw.
01 ren axe pis mWer�/jjSee. %f/ , B R I'C Iia this re vs
Owns::; e YJ �L LD:"c "/26/45d
is WOR IrSC IPEN5AI]ON DECLARATION
1 retch,attic,under,soupy nr pc,my one orme fnuowing declaradion,:
• ❑ 1 Lave and will aurin sin a Comfcace of Consent to xlt-ln,mare for Worker', .
Cumporoatlnn, as pni,idW fit by Section 3700 or the Llaa C;Mc, list the
perl'onnance of the work for which this permit is issued.
01 have and will maintain\Vader'.Compena.ion Insurance,as required by Section -
370(l of the LUM,r Code,far the performance of the work for which this,loris is
wed.My Workers Cntnrea atinn Laurance can'icr and Policy own@+are:
Carrier, Policy No.:
CERT IFICXHON Oh EKEMP PION FROM WORKERS'
C(IMI'ENSA'fION INSURANCE
Cutis cession owed oat be eumpinc!if the permit is Iia one hundred dollar..
(EBp,at los,.)
1 cenify that in the rerfnnnance of the work for w4ich this permit is i...ed.I
.shall not employ any person in any manner sons to bisonv subject m the Worker'
Cotapcnsminn Law,of Calif m. fate
Applicant hnu1J
NOI'10E'11)APPLICAN'r:IL no..n„king Ilii,Ccmlrcatcof Ementa er,yen c
lissometi
osubject the Waders Compensation provisions of the latbor Gale,you ams,
C) forhwith comply with such provisions yr this pemsh.hall be dmmed revoked.
CONSTRUCTION LENDING AGENCY
aI lictichy which thus,here in issued
(Set. leading09 , agency fur the rerfnmwnee '
fx7 of the wad for which this,intuit is unwed(See.31197,Civ.C.)
Rt Q LeWar's Nunn
ZD z LcnAer',Address
V 0 1 cenify that 1 have read this applicmino and state that the above information is
a, lr concis.1 agww m.comply with ull it,and county oNinunac,and eons hums.luting
Q V thmbuildiny contwainn,and thereby muhorLc repre,cnmtives ifmi,eity mentor",.
�•r e abavo-nwntlonei pnq,enY for Ingxvtina purposes.
y (Wel agree m,save.ivdannify and keep harmlc,s the Cityot Cupertino against
E' N liabilities,judgments.costs and expenses which may in any way income against said '
U
Cay neo"tnluc"«'It the gmnfing of this pennon ��—(}C—)
A"I'LIC\NTUNUERs'1'ANUSAN W/LLCOMP YWITH LL NO POINT Issued b Dale
)ll ,R000LATI S./f /J�r �� .� �^ y
signat "?NDE
Dmc Re-roofs
HA%ARDOI)S Mr\'rLN,1 ti UISCLfISUNIi
Will the applicant at future building acca,ral,mm or handle ha,,nloutlnmmral Type of Roof
as iolined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Coil,Section 25532(o"
0)'cs 0N All roofs shall be inspected prior to any rooting material being installed.
Will heappre;rrIo,talmebuilding oecupmause equipmentor devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit ha fou.,air romamimnts us defined by the It.,Area Air Quality Movgemcm
District? all new materials for inspection. Applicant understands and will comply with
CYes 0N all non-point source regulations.
1 www read roe ha.ardoar materials ev,mic nand under Chip,,6,95 nr the
California Hahn A Safety Crede.Section,25515,25533 ad 25534.1 undecaand that
if the building does not cone.,14.have a Rmml,that it is any re,rym,ibil ity,,rand,the
woman,of the rectors, at,whleL ams,tic over mini m smeasoc ofu CaOfeme of
p y' ant Date
Signature of Applicant
amu r a All roof coverings to be Class "B"or bluer
(/ OFFICE