00100186 CITY OF CUPERTINO
BUILDING Dl ISICN PERMIT CONTRACTOR INFORMATION:
BUILDING A13URFSS: PERMIT NO.
(IWNf:H'S.A _ 88 APPLICATION SUB INTII
J
I(INE: NANCY RITCHIE !:764 VjA:FI(3PjR[= AVE
SANI'1'ARYNO. - CONI ROL NO.
AHCHrrrCUENGINEER:
BUILDING I•IiRMI'1'INFO
BLOC ELECT PLUMB MECH
azta I-1 O lJ f-1
LICENSEDCONfRACIOWS UPI.ARArION Job Description
1 horhYadi rn;;L.I;; two n.cdendop.yislon'or Chain,9(vonunanuh,g
�y Fre vOi wllh5caion 901XB of Uivininn:Iof the hall „and V...la„lona Code.Indiny ll, n,c '
a`P 1,in full fmcc and,flat.
z
yse m License Clan Lie.a '
O a. Vac Canlmctor
J6u.� ARCIIITECT'S IyECLANAD(IN REPLACE 40 GALLON GAS WATER HEATER
t”g O 5 I unJemm�J my plain shall be used E pLARAI I N.
ESN
oo Li ob,od Prof e..wont
>. OWNER-BUILDER D[ChARAf1UN
1 herehy affirm that I ata exempt fro,,me Contractor's License Law for Ile
E_-'!, following reason.($,limn 9031.5,Bu,inaa and 11 1....ion,Code:Any city ar county /
` D 'l'ah rcqui rad a perndl I constrnel,alke7 hnprnve.dcneli,b.or.,an any struemrc
i3. prior.,,it,is..a—'.laomgnano,hodidiican,R,rSuch pemlit to Bile a.igned.mtetnent
m:u he 1,licensed par.aam a; IN, ,donor he Co,nra,W,Liuenae Law teeap,,9 Sq. FL Floor Area O lion
Inmaneneing with Section 9(XXI)of Division 5 of the Buxincx,and Profession,Cod.) O
nr that he in exempt therefmn,and the baai..for the alleged exon,ption.Any violation
of Section 7031.5 by any applicant for a permit.subjects the applicant to a civil Penalty
of not am than five hundred dollaa 155001. APN Number Occu jyjy_'�ype
01.as owner of the propenyl or my employees with wages as their rae dcompensation. 311 ttlt
will do the work and the structure i%not intended or olrered for sale(Sec.YIWd,
En, ` pe,and PruC,,i ,s Code Iract
[to Contori,C s Le law does nm apply Io:I Required Inspections
',I Property Who hnuda� a,dw.eml,and who a,ca such work hi owil 31638039. 04h
mthrough hi,oonn;pinyee..pn,mded that.anch Imps em,are not intended n
.11o.1 Ins solo.If,however,the nuilding or improvenent`is sola)within one yc;a n1'
m,n„phdoormeowolsalecrwBlnasemenaNanolBrovingmenedmnatnNldm 502 — FINAL PLUMBING ENERGY
pm.c theo nor-
❑1.a.nwaeronnepmpeny,amexewsmelyaommchnswhnfi«nsedcontrl 506 — GAS TEST
Construct the project(Sec.70.W,Business amf Profession Cade)The Com.cwr'a 507 — FINAL PLUMBING
License Law does not apply u,an owner of propcny who build.or improve.mnaon,
and who contracts for.such pmjeco with it umtr.a,r(O licensed pursuant n,the
CoMoN or's LiocMc Law.
❑1 non,exempt under See. .B&I'C fill this reason
Uwncr Data
WORKER'S COMPENSATION DECLARAI BIN
I hereby,Nim;under penally of pe jury one Ili the falluwing declarations:
J I have and will Maintain a Cenificae of CMsC„1 to self-insure for Workers
Compenahon, as provided for by Section 3700 of the Lnh,r Code, for the
performance of,he work for which this fiction is issued.
a 1 have and will maintain Worl,er's Cnmpem:niun Insurance,as required by Sotion
391111 nr the Labor Cil I,for alie pcnomnnee of the work Ibr which till%permit is -
mcd.My Workm'n C.np....aion fin wraact,currier and Policy numnc,are:
CuNen PnBry Nn.:
CIiR I IIBCAI ION UP LXEMPT1(IN FROM WORK17RS'
COMPENSATION INSURANCE
(This.action ncad not h:completed if the Pt is for line hundred dollar,
n 1 On or los..)
I cenily don in the Icrfonnance of the work R,r which Thisµrrtil is issued.I
,hall naI.Epley any pcnon i;,any..,.Inner so ax u,become.unlwt to the Wo kerd
Cnmpanrxallon Law,of Cul N M'.Date
APpllaum
NUI ICE T O AI'PLICAN'1:It.alio making hall Cotilloac of Excmpll eu.you should
t a,ome subjca u,the Werke-Congcnsaion pnowo...of th,
he Li r Code.Yom
u list
O Q forthwith comply with such novoitev.or this permit shall M darned recokaal.
0 CONST RUC ION LENDING AGENCY
' 1 hereby alliin,that there i,a o nNowtinn lending agency for the poforoon.
W uI he work for which this permit is issued(Scc HX».Clv.C.) -
S Q Lcndcr',N.amc
7 Lender'.Address
V O I cenily tlm,1 have re;ul link applica(ion z I state flan the abnva information is ,
4; �I c reel 1 agree a n,mply with oimuee all city and romy anlca and Lelaws releing
,I buildingcon.tmaion.and heehy MAhmim.p.anunives oflhis city I,enter upon
', 47 the ahwun,entionad plvpny Iia Ius,,st Purpne..
.r = (Wel green,save.indannify and ktt,hurnlesa the City of Cupertino against
Zi liabilities.judgmaaX,costs and expenses which may in any way accrue against aid
V "!. City in consequence of the granting of this.permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Signature of AppliauulCaalella Dam Re-roofs
IIA%AIIDOUS MATERIALS DISCLOSURE
Will theappueamor haunt MNdRe m
h,g Oa,ut 1... or It narardoa,n,am,ial Type of Roof
us dcPo,ed by the Cnpen ino Municipal Code,Chapter 0.12,and the Heahn and Salcty
Calc.Scctiun 255320'.'
0 Ye, 0 N All roofs shall be inspected prior to any rooting material being installed.
Will the applicant or future boilding occupan,..c cgaipmnn or device.which If a roof is installed without first obtaining an inspection, I agree to remove
;nit hamrdous air Mnt.ninunl..as defined by the Buy Area Air Quality Manasvnen,
all new materials for inspection. Applicant understands and will comply with
O Yc' ClNo all non-point source regulations.
I have read the ha..... s;nuenah re,ahe....nl,undo,Chap,,695 of,I.
Culihunia Hndth N Safc(y Cuda Semon,25505,29533 and 25534.1 Mai I Ihan
if the nuilding doe,no,anrrnnly have n rectum,that his my no,unisithuh,..Ellynhe
occupant of the requirements which m,L be met prime insuanee Of Cenifiaa,o of
°Cenpanc,s Signature of Applicant Date
o,..ne,orMahnn.edagent one All roof coverings to be Class "B”or better
1
OFFICE