01010033 CITY OF CUPERTINO
BUILDING DIVISION' PERMIT CONTRACTOR INFORMATION:
BU11.1lI,Jr 911RI71 R I ON PLT pr"
,
'�010033
owNlM41TIN SHAWArrl.l�aiu�N UL cf00I
PHONE; SANITARY NO C CON'rROLNG.
Mei ARCHITIRCr/ENGINEIiR- BUILDING PERMIT INFO
Ru 0 Fq0 BLDG IiLECT PWM M11ECf1
5 H j LICENSI)CONTRACTOR'S DECLARATION
$z=o 1herehyafinn,lamlamlicensedunderpmvisiona..r Chapte,9(rommr.eing Job Description
t-I—tin with Sexion7000). DlVluon3oftheBusine,sandlinshmion%Colde.,ndmylicense REPLACE WATER HEATER
i,in full farce and of 't.
a6e Doc
I I S DECuLtAorR
NION
1undeemJmyplmna,hal he used nspubic record,
s
u+—,g
o,O Licensed Pn,fe,mmial
n n OWNIiR-BUILHIiR DECLARATION
aui o ce ce I hereby af6mt mm 1 um evcur,from the Cammaara Lieenm Law for thr
1Z following sleflon 7359umins%nod Pithesi,win%L Any coy or coloov
$$ p when oci,ioc,b rot I ba,on,or.O.after. 1 J lkl p yin......re
da priors Nxmantt,Au occon-thenpplcanormch p.mtn file a.i,rbdmdunmI
— that he is licensed pmmurn ,,me prom,mviol me canna[...,•.Liceirw Law(Chapter 9 Sq. Ft. Floor Area Val0on
(eommenceiny with Section YaH)of Division t.(,he Business.and 11m(mel..n%Cade)
or that he is exempt thc.cliont and.he basis for the alleged exemption.Any violmi'm
of Seetla,t 7031 5 by any applicant into Penni.subject,the:nplicma m a civil"i'lly gpN
ulnar�wora Ilan live obehedmmwrs Matti) - - 39MA r00 Occupancy"type
❑I,us owner of the property.or my employees x ith wages as their sole conirsobation, eJ 44
will Jo the work,and,he%wmmum is not intended or offered for sale(Sec.WW.
Business and I'rofe ors Code: The Contrai License Law Jots not apply to an .> gg p�y�,�yy��� pypc,C�pp�,
..net of progeny Who nada,or improves thereon,and who doe%such work mm%dr 50t_ — FINAL NLM M6 f IVCs t tRGY
mthrough his own employees.provided mat such improvements arc not intended car 506 — GAS TEST
offered Ib,ealr.II',howevm,the huildiog nlmpro cnt IsId widow n c yell,of
omplehmt,the owner-hddafl
e,will neve enm
� cbe nal dosing oat addm
na ad..' 507 — FINAL PLUMPING
improv,for pumow n1'sale.L
❑I.as owner of the property.am xclusively contracting with licensed endtmaors to
momma the project(Sea.7941.Business and Profession%Cmle:)'Me Con umour's ,
I.icemv Low does not apply loan owner e1 property who builds or unproven thereon.
m I woo ammem%nor nada pmjacds calor a annm.nons) licensed personnel to the
Cnntrunor's I.iucoa Law.
❑1 not vitamin under Sec. .B N 1%C Redo,mann
Owner Date
WORKER'S COMPENSATION DECLARATION
hcrchy nl'linn under Pe nilry of penury Ile of "How log dmumni..ns: - -
❑ I have and will nainmin a Cenificme of Constant to sclGinsu.e for Worker's
Compcmnmidn, us proviJaJ fur by Section 37q) of the Littler Cade, for the �'�
/�
priformanccof the wit s for w Inch this permit is issued LEp
❑1 have auI will maimnin Winker',Co etwovoion Inraanee,i,,mored by Seeds i /�\
37h)n1the Labor C:xle, or the fictional a..1 0r work for wbkb thin iwmti,is
ism IT My Workvh C..ntpen.m ser Instance carrier oil
Poh,noodle,arc: OCT 0 rl 200
Canicr:_&C1 0 'ION OI�O_EC(icy Nei
W(IORKFHS'—��' i7
CcIMrBNSATION INSURANCE BUILDING
('Ibis oe ion need not be complcrad'I't he permit is in one hundred dollar,
610(4 dr le".)
1 ceniiy that in the pirfmmonce of the work for which this permit is issued.I
shall not employ any person in any manner so as.o became subject to the Workers'
C....i"i'dio i Low,of Cahf..mem.Date
Applicant
NGTICE TO APPLICANT:Ir,aflrr naming thin CCnlllcudv of Exemption.you.should
become bjccthe Workerpcmtinon, Lasso,'%Comun provisif the Lasso,Omr.you mum
wi%iomn forthwith comply with such pdor this pemtit%hail he Jemind reveled.
Z O mna
F' (Z) CONSI RUCTION LENDING AGENCY
1 hereby arena,than there is a construction landing agency for the pertomancc
of the work t..r which dhi%pernd,is ismeed(five 31097.Cl,,C)
y p Lewder,Namc
Z, Z LenJcr's Across
U C I verify thin l have road this appliemion and mate that the aline information is
4. Es correct.I agree to comply with all city and convey ordinance,and state Iowa,dating
t..) ,holding eonsmanlan,and heochyemhorirc beprcemmivm It this city in utter upon
'ydnuibave..nndinned I lily(aru,cnlnnput pan es
11s. (We)agree Ios;rvc,IndmmnifYand kec acne Chy of Cupertinr aguinnt
V] liahiloiea,)udgnamn,enan and expen.as [It mit o any way..acme against sail
(J Z City in crena 11 f the gnnhng oft v isnot..
APPLI DERSfANUSA ILLC PI WITIIALLNON.F'OINT IssllCd b Date
SOI' r l UTATIONS. J =✓�' y'
Signnmrc of
tp ana/Lbmoco,r Oban Re-roofs
HALAROGG MATERIALS UISCLOSUHIi
Will the li,h,am or runrc•handingoavpom moteorhandle hemodhonaarlal 'type of Roof
as Jelined by the Cupertino Municipal Code.Charter 9.12,nal the 11ca1tb and Safety
Cade,Section 25532(.)!
0 Ye, 0N All roofs Shall be inspected prior to any roofing material being installed.
Will the uppOrnt or tomre boldhag:xeopmtt use c:rvgno[i:t at dea;cc%winch 11'a:roof is installed without first obtaining an inspection, I agree to remove
snit hmaodous at,core;unin:ma ns defined by the Boy Area Air Duality Mmagemm,
District.' all new materials for inspection. Applicant understands and will comply with
. OYcs ON. all non-point source regulations.
I Love read the haaunmus materia,rec real under Chapter 69.5 of the
Culiem,iu Health ffi Salcty Coale.Scctium .,25..3.nJ 2.1534.l malcnnnul that
ilI hollJi meens,s nave: anions.it' ,nyauanc...
Ifo cemli'fy the
cepa ter r mens which usdnlw not or m issuance of a CertiBcum of
OW an[y' u e / �Y Signature of Applicant Date
caner nntmh I-- tiller, � aDJtre,, All roof coverings to be Class `B•' or better
OFFICE