00070053 CITY OF CUPERTINO
BUILDING I ioasnRV
95u>N IT CONTRACTOR INFORMATIO : 00070053
HUHDING ADDRF_S5: NAP- PERMIT NO,
07/11/2000
OWNER'SA [:: APPLICATION SUB DA[Ill
111IONI: SANITARY NO. CONTROL NO,
ARCHUDIM ENGINFER: BUILDING PERMIT INFO
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❑hDG ELECT PLUMB M1IIiC11
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1. 1herebr aui;;°N11i1).C(1N uaeauder pro knout 011,"ler 9 rsnmmcneing AC/FURNACE Job Description
Fmtw w hm Sortimn Brorc"xand P-osmium Code andn,y limnm
ax5� i,;nl'ull6,mc vnJ el t
x¢ 6 I.icmn,m Cln -= Lic.M_I`b 3
X P a u nam_7r1r/o_O S DECLA —
3 p G ANCIII'I'F,CT'S DECLARAIIIIN
I unJemanA my plan.doll be uuJ o.public aeM.
5 o c 1.ianxeJ rmresammd
OWNER-BUILDER lit-CLARAI ION
hereby a1'Iirin...1 ale exenpl frnln the Onnmis Co e:Any Law fur Ibo
H%� lid nh nermin,,on.sl�eouel ,]IoII S,mliexand nupaor,dr;nnxiro, Anycity ,lor,oly
2 o which rats ko a pcnaih ro ron9ma,ahsc.Improve,demolish,or repair a signed statement a3°9 this heixl;enancoostam to ihepevpphnmfo,wcc,knn;nnfilcaaw(Chmnen,
,commiscing �Jpm>u:mnn00oof rOxinfmc Co"mavAs L;censc Lswon%Cor9 Sq. FL Floor Area Valuation
(commencing with t therefrom
]m anof Division 1r the a Hmine,s and Professions Codd
or hha he is exempt and the hast,for the alleged eaemp,inn.Any violation
of Section]031 S by any applicant for a hermit subjects the applicant e)a civil penalty
::f not more thanSvehundreddollars(65(ah. AP m er _ Occupancy Type
❑I, f mo pro, ty, pliy rel Iour Baas lWi I"'to L'supen,anl,
III do the k A 11 'I' :I I 1 Ifel t (1 7044 J J —
ntid dl f:.ro f. lo:TT c I I 1 L: d 1ply It In 304 — ROU I
wee
r of propeny Who build,or in,pn,vex thereon.and who does such work h mmlr d
to,hough his own ho%c%ceex. Wildin mat such;mpmvcmcnl,arc no,;mended or
nlTcrcJ for,ale.If,howcrcr.the building or in,provonem is mIJ within one yn,..r 505 — FINAL ELECTRICRL
completion.me owner-builder will ha.rthe Weeden Nproving mm he did no,build nr 508 — FINAL MECHANICAL
improver p
fourpse oof'.1c.).
❑I,ax more,of the prime,and exdu,ivdy contracting with licensed common,,to
nwcl,he project(Sec.7194.Bussand Profen %Crfep :a
e"
'I he Coneter's
Lm
icc Law doe ua appa ly ol pl'npany wen h uld,or imps es Ibcreon.
Cori who commm% r mud:pMjcav wish a cuneaeenl ) IlecnnM Pnr%unin In the
C1ntractor,L;csmke Sri
❑lam steam]ander sec. .B&Pr.tor,m,reaan 2�„��
Owner Dae , A
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the tollowing declaration. \�
❑ 1 have and ,ill inaintain a Cenlficnte of Csmcn, ,m selGinme, far Worker's
Colnper,u,inn, ns pr.wiJed for by Soalm, 3700 01the Labor Code, fur Inc
perfun eemo Noe work on whlcn tlli,panni,is issued.
have and will maintain Wnrkcr's Cimence,a,in i Insmence,a,required by SeNnn
1700 of the Labor Csle.Rr the performance of dm work lir which this pennh is
issued M1/111���'• p�Rf,/:nm n,+,it nwmnce came,and Policy"times,re:
Carrier:L�^L__ Percy Nn:E G[{tr! 1 7
CER CA] R%EMYr1(IN FROM WORKERS'
CONIPENSATION INSURANCE
(rhin eYlnn"sed nal be crinp,lel it psr nil i,he arc hundred dolhe,
I5110p or Icsx.)
1 cenily thet in the perfnnnunce of,he work for which his perm;,i,lssm,d.1' -
shot]nut employ any pl:rxon in any manna,m as,o become subject ,,,he Workers'
Compensation Lana N Califnnia.Doc
Applicant
NORCE TO APPLICAM':IL after making this Constru,of Exemption,you shnulJ
hee,me subject it)the Workers Compensation position,of he Labor Cade,you must
Q 0 forthwith comply with such proviOun.or this poem)%hull be deemed revoked
ti CONS'I'RUCTION IAN DI NO AG o0"
UNCY
a 1 hereby;it Intl that Incl u'w a constmeliun rdin,agency for IN Pe I'onnunee
of the work for which his por Ix in%a.d(Sec.1097.Ci,C.)
L Q Lender's Name
7 z 1<nJer',Address
V 0 1 certify that I hive read this application and shite that,he allure information is
cons".I agree to comply with all city and county ordinances and stale laws relating
U :i:
mWilding construction,and hereby aohodse ote,w"alvn of this city to enter urym
c atov,-nenunned pmpcny far inspection rambles
(We)egOolu,or.imlermifyaed keep hernlless,be Clly of Cupmtim:r,ono
liuhiliuc,,judgmnns, and sxpsnm,which may In Imy way nccnm age;n,l nail
V Chy In amv,cyuenec of Its Forming 01'Ill;x pcmJ1, 1
APPLICANT UrypG DS AND WII.I OMPLY WITH ALL NO:`� NT Issued by: �"� Date
SOURCE RE IONS.ONS. _ � it/du
si'mume uf,pp,m"atic'm ac or U c Re-roofs
HA7A DOUS MATERIAI S DISCLOSURE
Will the applicant n,rmtim Wilding n'ctipam store or namlle nosank,m twmrial Type of Roof
as retired by,he Cupenmo Municipal Code.Chapter 9.R,and,hc Hml,h and Safny
Coda,Section 25532f:0't
El ye, All roofs shall be inspected prior to any roofing material being installed.
Will lie lmpreimm morebwlding"ecu„enl,mccgaipmemordesire,which If a roof is installed without first obtaining an inspection, I agree to remove
cluil ham,Jo.,air nmten,ione,as defined by(lie Bay Arca Air Quality Mangcmcnl
umtrie,7 �� all new materials for inspection. Applicant Understands and will comply with
0 Yes all non-point source regulations.
I have,cad the ha"urduur materials ecgaimmen,x under Chapter 6.95 of the .
"lifomia Health&5rely Cotte.Sections 25505.'_5511 and 25534.I understand that
it the buddig does ten currently have alenam,that it is ,,y re,ramihili,y to no,;ry me //
//�tlU
:xvvpom of m f,qui m Is which must W me,prior to issuance of a Cee filee,of 111
II` °'eti'sey;/S Signature ol'Ap icant Date
/1//OU
Ownerml,mhmir.ed >"Ip All roof coverings to be Class"B" or better