01010131 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERM I r NO.
F.?011;3 11MTl-CF S' ;30 JUST WATET� l-EATE 'I?) 11,I1C 01.01 .3
OWNEWS NAME: APPLICATION SUIT DATE
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.,PHONE: SANITARY NO. CON'TRO1.NO,
Mai ARCHITEC 7HISCHNEER: BUILDING PERMIT INFO
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S v;6 LICENSED CONTRACTOR'S DECLARATION Job Description
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O7 C 1thereby 0)of Ni am.3IicenuJvines and Profsof Chapter9(commencing
p_Cm wilhsectioomand of Divixinn3of the Beninese and Ymfewiom Code.and mylicenu -
6,CC q a ec lid!force nnJ effect.
SCK¢ [)are wClur:v Conn f�f:J�9._A(.:I '�a(%1 C•iAI..I...GPI GAS WATER I.1f_llTf-S;
Wy 3 0 To Dae ARCHITECT'S
hall wu DECLARATION
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t g�3 1 understand my plan,shall bo awe a.,panne recants
O O I.Ieenmd Poar,,innvl
o� Dat I am eviapBUILDER m1ite Contractor
lyvl=' 1 hereby alRnn then 1 e empt from the Gmtmctor's License law for the
believing reason.(Section 7(ULS,Business and Professions Code:Any cit or cnunry
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Fc vilhich requirespc tit to,construall. II r,malasse,demolish,or retain Tinystructure
a30�
prior it) also -In 'prlic u . aI ...I or I a,i,olvd,linend
math is trellised l .aa II due p I,offal C t Inter Law claratro Sq. Ft. Floor Area Valuation
(commencing with Section 7000)of Division 3 of the Business and I'mfcssiom.Gdc)
or that he is exempt therefrom and the basis lin the alleged exemption.Any violation v
of Section 7031.5 by any applicant for a nation subjects the appreant ht a civil penally
of mol it Iran five bunmnl dollar,,($500). APN Number Occupancy Type
❑I,m owner of the property,or my employees with wages as their vole eo:opeasation.
will do the work,and the sructure is not intended ,,offered for sale(Sec 70Tm,
Bas and Pmfassinne Code:The ComrnIn
mv 's License Law does not apply a Required Inspections
w reef property Who bnildv or improves tbaman.::rid who dtev vuch work In wlr
nr enough his own hoever.employees. building
per each Ina int is anif,sold are not one year
or L.f 7 ... .f
oBcmJ for cele.If,hnwo-ar,the building or improvement is sole within one year m �ICk_. I°7:hIN._ I'1.1.lf"IC]:I IG E"Iy0J4GY
completion.the nwmrl,aimar will have the burden of proving that he did not build or 506 -' GAS TEST
improve for pa:mtw of sale.).
❑I,uv owner Project
p(o)esy,:nn a Business
d Prof'ing with Code:)
nT ....Contractor's m
;eEY7 FTI♦IAI._ F4_UIIBINCi
Livens et the pmjtet(Seel 7(144.Banes.and my%Monti ilei,or The improves
traanr s
anI Law Ates not apply m an owner of progeny won huilds or imPmvea thereon,
nil who nLimee for well projexx with a contractors)IicenuJ punuam m the
C I.,itr is License Luw.
❑I am exempt unJcr Scc, .11.0 PC bar this moon
Owner Data /1/
WORKER'S COMI'ata ION DECLARATION G
I hmeby apron mde,le salty of 1<dury rote of the rvllowing declaration
a❑ I have and will maintain a Certificate of Curator to sell inwm for Worker's r
Compensation, as Provided Iia by Section 370X0 of the Labor Coda Ibr the
performance of the work tin which this permit is issued,
❑I base and will maintain W Jar's Ctuatereation Insurance,as requital by Section ..
3700 of the Labor Code,for the perfornunce of the work for which this permit is
issued.My Warom'n Compensation Inwmnce cmnm and Policy number are:
Cradac Policy No..
Cr:RI'IPICAIION OF EXEMPTION FROM WORKERS'
CONIPENSAT ION INSURANCE
(This section need not be cmnpleted If the pernel is for one hundred!dollars
61(0)or lay.!
1 men,that in the Nrommoaace ol'the work lin which this pemmit is i...ad.
shall not employ any person in any manner m as to hecome,subject to the Workers'
Condensation laws of California.Dale
Applinmt
NOTICE 10 APPLICAN P IL alim nankin,this Lroff,a a of lixanphnn,you should
McoWorker'se subject to the Worker'sCompensation provisions of the laborrion
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Cole, m na
zQ O forthwith cnntply with such provisions or this permit,hull he declined revoked.
Vv,.I1 CONS'TRUCT'ION LENDING AGENCY
> 1 hvnhy affirm atm Fere is a eonutmeann Icnlhug agency tin the pmromaume .
office wad for which this permit is ovwed(See.Ln],Civ.Cd
0. Q LenJcr'v Name
] z Lender's Adults,
C.7 Q 1 certify(hat I have rcntl this application and ,are then the above mlorn:ueun is
rao F cortex.1 agree to comply with all city told count ordinances and omv laws refining
Q t.1 to building consintction.and hereby outharim mpmuntmots.of this city to emir upon
W the abovcmcialincd pntpuoy for nspanall parm'wv.
F d (We)agree msava x
uni ::o 1
it,ikeep t ills,fire city of eulertilloagain"
V] hololilin,pmgmcnu,m 1,and evpenso which(nay in any way;,,true x,ina,f said
V Z City in con.vi umm of granting of this)mint.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI•NON-POINT Issued by: Date
SOURCE REGULATIONS. Y
Signamrcafnpplicanul'onmelm UuI° Re-roofs _
BAY/,RDOUS NIATERIALS DISCLOSURii
Will the applicant or future building recupant store or hamlle Infatuations material Type of Roof
To,defined by the CuIv nino Munivipal lade,Chapmr 9.12,and the Health and Safety
Coro.Seclinn 255320)!
ElYaa DNo All roofs shall be inspected prior to any roofing material being installed.
Will the applicant nrfuture building accapaduse aximpmanor devices which If a roof is installed without first obtaining an inspection, I agree to remove
limit hilarious air commainunu as defined by the Bay Area Air Quality Managanem
Dihtncn all new materials for inspection. Applicant understands and will comply with
09oa ElNo all non-point source regulations.
I have read the hvurdnus materials requimmcroi under Chapter 6,95 of the
Culiloo is(Health 3 Safety Code,Sections 25585.25533 and 25534.1 understand that
If till building duo not currently hada a narem,that it is my revponvibility to notify the
Pant of the requi Inwnx whish moa be ata prior to issnuaty of a Certillene of
Ocuccupancy, - Signature of Applicant Date
Ovaerm art tmiled octal Date All roof Coverings to be Class"B" or better
OFFICE