00100221 CITY OF CUPERTINO
ne•LgINc DIVISION PERMIT CONTRACTOR INFORMATION:
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fl1111.DINf:ADDRESS: PERMIT NO.
OWNER'S AVVe Ni 50. APPLICATION SUB DAT Ur-+
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HUNL AND —1 tABE "`a 1 GRRGEI=APID — SAN]JARY NO. CON I ROL NO,
n re p ARCHI'I'EC'PF:NUINIiIiR: •— flUILU1N0 PERMIT INPO
w C - BLDG ELECT PLUMB MUCH
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LICENSED CONIRACnderp DECLARATION
= 1 heren ism,mm I am fi<ef.ea under r Chapter 9 g � Job Description
o f"— provisions a per (eommenens
I'mfi fill Last,
agB of Division 3 of the Ruciners anA l'rolesciore Code.mW my license
a ar< ie In lull(ince amt clrcat.
�sara ])are..a:rt Lica REPLACE WATER HEATER
0 6 V Da1C1 , Cmllmclm
ca. - ARC No used
UECfARA PION
0 understand 1 unaeanJ DIhall u
Y Plan, he uuJ a%pontic mulls
adw aj O O LianacJ I'nRcstional
t3 hereby mov .(Sea o nl 1. .Rusin from the Cnmranor'e License law far the
L a following rwson.(Seaton]BJLS. duns and sae,de o demolish.
Cale:care
city a err murre
`F c xh¢M1 rt4 .fit 1 1 1 II P J I.n pa y Iruclum
ce
ment)its issuance.almi requires the applicantl h arradf file igned.mremem
that no is I canedPastern tn p l he Coca factors Licame Law fchamery Sq. Ft. Floor Area Valuation
(c, c +gwtheSea lot,91 X11,I Division 3"1 he Ihu,iraandlv...I ear,,Cute)
voIh: e I, rep ta<mlmm and the ha,i,for the alleged etcm ciao,Any vinlafinn
f Sercraft hnn 7031.5 by any applicant file it panno nubjecis me applicant to a civil penalty
of not more than five hundred aohar.($5110). APN Number Occupancy ype
❑I,t1.s owucr of the prep<•ny,or my cmpinycex with wages as their sole uampemation, _
win Ja life work,nail the,....em i,ren IntefJM err ,Il ed far.rain(Sec.7044.
Bon.fee,,and pole,ite,Code:'ntn CD+hnflor\License Law does ren apply D aft equired Inspections
r cf pb,,.y Who Wild,or improves d¢man.Ona who does each xork himself
or through his own employees.provided that such improvement,am not intended ar
offered for sale.lr,however,the Wilding(impmvenocnt is old within one year of 502 — FINAL PLUMBING ENERGY
hav
m+pletion.Ino owneonnilder will e the burden of pawing chat he did oaf bu11J or
noprove lar paepo-of.ule,). 506 — GAS TEST
❑Las ownerofnirNm,,nr.amexclusively contracting with licensed contractors to 507 — FINAL PLUMBING
License
Use project(Sec.]Ott,(or net o and Proeasy who
GdoB The commrcon,
License law tact not apply to an owner of a courrwhn halide or sed purse a tto the
an whn nmuocr,for such pmjeax with a emlmaor(s)licenced pursuant to the
Conenemr's License law.
❑l am vumpl order See. .B&P C for chis reason
Owner cmc C
WORKER'S RNSATI DECLARATION
I hereby nflinu nnJcr penaltynaly pe
al rjury on lilt of the fiJlowing Jcdurmionx.
J 1 hmc xnd will counci i. a Cenilicad of Convert n,ml4in....far Worker',
Compensation, as provided for by Section 3]11 of the Labor Cade, for the
performance of chc work fnr which this permit i,issued.
711 have Ona will red Lulain Worka't C'nmpatuacion Insurance,as required by Seclion
:1911 of the Lake Code,our the calleruo:nme of clue work IUs which tl.'..permit iv
auN.My Worker's Cntnp.mmion trammce carrier and Policy another me
Carl Policy Nu:
CENI'I icsifON Op Ii](pMV1]ON FROM WORKERS'
COMPENSAI]ON INSURANCE
1'noi,,ection need not be contptacd if the parent in for one hundred dollars
IS lull or Is,,.)
1 ocill y that in the performanee of the work far which chis permil i,issued,I
,hull nut endplay any perrem in any Deficits so as to h,conm.ubject It,the Workers
Comper,ntiou Lrwx ul Culikania.Dam
Applicant
N(fflCli 10 APPLICANT,If,after nuking this Certificate of Eaempfion,you should
Obecome.ubjen in the Worker',Compensation provisions of the Lahr Cede,you mitt
fonhwhh confply wish inch provi,ion,or this Pettit,hall be decreed revoked.
T n
F .(4.a COl here,,con,mactio)INO Af,ENCY
} I hereby which that there i,s con,wainn lading agency lin chc pvrmmmnm
of Lechc work for which 1i,permit i,issued(Sec.ill],Civ.C.)
iG Lento's Name '
z Lcndcr'.AJAm,.
1 certify Intl I have telt dor appliccti I and slam eon the above Inf+nnuenn is
W E~' anrc<1.1 agree in conicity with all city and county ordinunecs anJ tune law,false n,
U u,Wilding eociwoulican,and hereby authorize repreaemalive,of this city u+color upon
} W the alxwometnioned prol for Impaction purpnes. '
E1 (We)agree to save.indemnify and keep hart the City of Cmadmio egaanm
" W linbi li ties.judgmen¢,cn,..and eapenws which may in;cry way acres igainxf.said .
City in nm,aquancc of the granting of this(vomit.
SOURCANYU DURSIg DS AND WILL COMPLY WITH ALL NON-POINT' Issued by: Date
Signature of Appr<acYContramor Date Re-roofs
HAZARDOUS MN'[iRIALS DISCLOSURE
Will lhaapphram or foam banding fccipait 1101 m handle hnlludearmamriw Type of Roof
I,defiwJ by the Ct,sm Municipal Gale.Chtmicr Y.12.and the Ilc:dlh and Safety
Code.Section 255}2(m'!
Dye, 0N All roofs shall be inspected prior to any rooting material being installed.
Wier the quid cart or future hudding occupant use equipment or des ices which If a roof is installed without first obtaining an inspection, 1 agree to remove
miI hwanlou,ter.....laminate n,dclin,d by the filly Arca A.,Quality Munagca
nnt
,ilrwty all new materials for inspection. Applicant understands and will comply with
oyes 0N all non-point source regulations.
I have read file hamolous mulcrid,requirements under Chapter 695 of chc
California health&Sway Cole.Section,25505,25533 and 25534,1 understand that
dine ntfddingda,x fill....mail,haven tenant,that if II%my rexpon,islay 1n unify 1e
rupwu of the myuit tncmx which tilos(be mel prone+I"Innee ul a C"(Beata of
ecup.a,, Signature of Applicant Date
Owner orauthe ieea agent Date All roof coverings to be Class`B" or better
OFFICE