01040082 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
l
OWNER'S NAME l APPLICAT ION SUIT DAIS
29,911
.1 PHONE: SANITARY NO. CONTROL No.
n alt NCO RCHr1EC'UHNGINEER: BUILDING VURMIII i)
U BLDG IiLIiCI' L J MI!CH
K
yea
LICEhanI.CU.croedrderfI3ECLARAChaptION Job Description
1 Damn IEnn Imo 1 nm oldie
ander !lino n J aan+n+ecen+
�Z^G hereby Dmvi>iumo Chapter g
Fm Fu with&c"an and nrDivininnJol the liu,incss and Vmlcsinns Clado,unJ mylicen,c
W Y in"III tome INA,�f =t
�cara i`ieenw:a.+. (��Q— Lia.« REPLACE FURNACE AND ADD A/C
3 N Dam m Conu:uana
ARCHITEC71"S DECLARATION
t a O 1 underunnd any Plum.hall M used as Public records
CLL F
y O O hlamscA I'rutest unal
A'o LL OWNER-BUILDER DECLARAI ION
=+m I hereby atlirm that 1 um exempt from the Contractor's License L my for the
following m sno I Sion 7031.5.Boiuc,,
Incl 1'roRse n Code:Any city:+ Lir+ty
E x M which mg ..atma permit to mov,mucn,alter.ingsmve.dt,malish,or repair any suuctnm
µ6t3 Prior to lL i,ntmnu.oleo rcynireahc applicunl fnnu,h lrcnniunfilcvsignW emmnmm
Thai he i,licensed ger,maul.da,powsimnsmMeconamo'.Liaim,".(Chapter 9 Sq. Ft. Floor Area - Valuation
(commumcing wine Section 7000)or Division J of Ileo Business and Pa fes%zons GNd
rz Into ha is mennul mere b'enl and the hasi,for the allcead exemption Any violation
of Section 7031.5 by any applicant pan permit%Injects the applicant no v civil penalty
Isnot mare than five hatndred dollar^f5500). APN Number Occupancy Typ
°1.as owner of the prepat or my ciaployec with wages in mar sole,ompenwtion.
will to the wok,and Ibe,mule 1.nal 'Intended at onced for sore(see.7094. 32 .rte
anorn,,and pride...Coderntra
rhe coctorL,w o ala,License dar,at apply an 'itcgw-red Inspections
as r of progeny Who bailds or improves thereon,and who docs such work himself
or through his own employees,provided then such ingvovcmeas arc not Intended nr
offered for wle.If,howeser the budding alt improvar an is cold within one year of 204 — UNDERFLOOR FRAME
repletion,I no owner naildet will nave the handen of proving Mat he did act build or 2401 — ROUGH PLUMBINGimprove for pary,we o1 5:de1.
°1.n..awncc on he pmpeny:..,neml....III, licensed onatlenng won linsed enntrnetn.,In 303 — ROUGH MECHANICAL
anstamme project(Sm.7044.Brame.,and Professions Cade:)Ise Conaacmrs 304 — ROUGH ELECTRICAL
la,erw,Law does Ina,apply m em awnet of property wren nand,or imIn
pmvcs creon.
and who contract,for such g deet,with a am raemto)Eecnad pursuant to ale 505 — FINAL ELECTRICAL
Contractor',Lumnw Law.
❑1amc.canander See. ,B&rCour dd,reason 507 — FINAL PLUMBING
Owne, Date 508 — FINAL MECHANICAL
WORKER'S COMPENSATION )ECLARATION
Ihereby amamm,derpetndlyof"jury ana'It te follow lnedeelamaan,: 514 — FINAL PUBLIC WOR xS
° av
I he and will TualoOle a Certificate of Consent to sett-innurc far Worker'.
Compensnaan. as provided err by Section 3700 of the 1,awo CWe. for die
per01 ha an will
work for which this permit is issued.rocs .�
❑I have and will nuinmin Woile pe Compensation of t e work for
as required by nniien IT
iolm . the Luno,Code,for the perinm,anee of the work 6r ream this pemni,Is /
iswal.My N'nrkcr's C.o/�fm��/fJje�//y,nwnion insurance carrier:red Itdlcy n`u�^n�h`�r'a�'`'r'c: ,
Can let C ICAit(IN OPI'.KBMPoli,PNo N(1N�R,,al LLS' � O/
COMPENSATION INSURANCE
(This section need not be canndirat if the permit is for one hundred dollar
($Its))nr less)
1 cenify that in the perionnunce of the work for which this rennin is issued,1
,hill ma enteoy Iny penv+n in any Damned eo u,m hexon suhjee a,the Wnrkes.
Compc,nmion IWw.of California.Dar,
A,111;aa
NO]ICF,TO AI+1'LICAN'1'.IL her nuking chis Ccnificam cf 17xempbon,you shield
become subject the Worker's Compensation provision,of the Lallor CWC,you amst
Q O I'onhwim comply with such Pmvisian,nathh pal'wh,hnll be deemed rcv,Aed.
f ` CONS]RUM ION LENDI NG AGENCY
CL1nearby vtirmthat more is n emon¢tion lending agency for flat,resfmene,
of the work for which this pcmnit is i..uoil(Sec.3097.Civ.C.)
i C Lender's Name
z Lm&r',A ld.,
V Q 1 exnify thin 1 have rcud this opplica,ion and.stat,that the amwu ialoollation is
ta, F, correct.I agree(1)comply with all city and county unbalances and slate laws miming
Q U mIsentllding k ,c
eam, cllan,and hemby amhodmm,a. rmivc,of this cal In enter apron
ahwamenuancd progeny for inspection purposes.
(• y eWclagraetosave,1,;old Duandnne,keep,nt,on the City of Cupertino against
V] IinM1ili,ien,O agree To
mets and expense, eep h may in any way mcnm ugaim,weld
f„) City in conmequcnce of granting Lir ,permit.
PPLLCA "UNI SAN ILL COMPLY WI'I'fI A{.1{NON INr Issued b Date
S UR cEGULATION �O//1 y'
s�gannta icnrntfcantrtl uate Re-rooys
kIA LIRE ) S MAI'IiRNI ti UISCLOSURIi
will me appbcalnt orf , hllitding a<c,apalht ante a,Bernal,n;r.awan,amatedal 'Type o
a..dalned nr mm apcnino Il,icipal gale chapter a.Iz.ane ma unarm anti s:nay .
C,xlc,Sucninn 25532(nl'!
All roofs shall be inspected prior to any roofing material being installed. -
Will heapplieaaarnnum boiling a<t,leantuse egnipleatordevices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hamnnus air cnmaminum,to.def cJ by ohe Boy Are.Air Quality Management
Diadmp all new materials for inspection. Applicant understands and will comply with
I
El yes 0 N all non-point source regulations.
I have read the ha ardoa,.materials reytlimn,,:rns order Chapter 6 9 of,be
California Health&Safety Code,Sections 255)5,25533 and 25534.I understand that
H oho building Ace%not curmndy have a tenant,shat it is my resgunsihility to notify the
in eupanot the mcpaiarmmnn,wnicll Inca he met prior fn i„n:mcc of t Certificate of
occupancy. ,
Signature of Applicant Date
Owner or authorized agent Dat, All roof coverings to be Class `B”or better
OFFICE