00090002 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS, PFRMIT NO,
OWILIER'SNAME11147 I APPLICATIONS
PHONE: r ENG WALTER T TRI.I5JrE_X7- F _ SAI'l NO. ) 99n
CW O O ARCHI'FECr/ENGINEER: G — BUILDING PERMIT INF((
F HL1lG • IiLE PLl1MH MI[C
rto
S y S LICIthat I a nseunder'$DECI.ARA('ION Job DeSCFIptIO❑
1 hcrcby ollirf'noel I am of
licensed under provisions of n,Chapter Cose. 6mn,license
with$ectian7gM)7 of Divii nJufthe Bmincsand Pmfeaiom Gde.and myicenm
'n full Inrce HeSy. 70
z s rcense lass` � 4 Lie.N
xo� n.,,r _1 Commel A/C
— FURNACE
FLL O ARCIIffECT'S DIiCLA ION '
_ S 1 undcmm�d mY plant+hell he uwd a,PUM1Iic rett,rJx
z <I Licensed Professional
i x OW NFR-BUILDER DECLARATION
1 hereby affirm th,n I:nn exempt from the Contractor..Lmen.e Law bit the
CLQ hullo h StanStani 170314E 11 e,,i C le:An,ail,olatn'y _
IFC uli ch y ' D II o I 'll tP do Ird p''r an,,vuuure
ad C3$ jai rta ns issuance,also requires . proof the apps oral for uchll file signed statement
a. mat be is licensed Pursuant no the previsions of the Contractor.Licen,e Law(Chapter 9 Sy. Ft. Floor Area Valuation
(commencing with Seen I BXXq of Division 3 ifthe Business and Pmfessiona Cade)
u that he is exempt tnerefnnn and the basin for the alleged cumption.Any violation
of Section 7031.5 by any n,licxnl for it permit object,the aP,heou to a civil penalty
of math than Evc hooted dollars S560). - APN Number Occupan
01.its ownermthe pw,try.ormy employees with wages as their:ale compa sumn. .
will do the work.and the nwcture is not immadetl or offered for sale(See.7144, 7.700
Business and Professions Cole:The Contractor',License Law doe,not appl)to an 356 9iL90red Inspections
owner of pmpeny Who builds or improves thereon,and who docs such work himself
through hie own employer+.provided that umn hnpro mob are nit intended u
orthroughtar sale,u:haw era ew holding or myna ve„ sold within ane year ai 303 — ROUGH MECHANICAL
.aplcaan.the owner-milder will have the norden of pro ing Ilan be did oat ba11J nr
impm,c larpanwneit.ale.)' - 304 — ROUGH ELECTRICAL
OLaxowner athe pmpeny.amexewti+elycontracting with licensed comments 505 — FINAL ELECTRICAL
causation the project(Sec.7VLL Business and Prideuians Code:)The Coulawa r'e
I.ieeuse I-aw does non apply n an owner of properly who harts or'anprovc,thertan, 508 — FINAL MECHAN I CAL
and soba nntons fia xrelt pmjatx will, a sontmemrl0 Is,nod pumaao, e,in,
nlnn'lor'n L amxc Law.
ra
0t.oran, pt.under Sec. .If A,P C farthis recd
Owner Dae
x'ONKEH'S COM I'ENSAf1ON DECLARATION`
herebywffilill ani
facilityCa ol'pnjwy onooftheo acil-ins r,for
O 1 ,not and will maintain a Ccniticati if Consent t sdl'insure for Worker's
Compcnantion. a pork f r fir by Section Jissu of the Labor Crde, for the
performance of the work for xhicn this pcmtif is issued.
❑1 hove and will a,donain Worker's Cma,wa xi n In....our,as required by Section V O
3700 of the L.ahor Cod,Ib, ,he perh+nnwce of'the work ht,which(his.punnit Ix
m
i. ed.My Wodcr'e Compeneation11nsumnce oarri/rar and rPo—olliery number are:
rtcC4' ncleNn,LLT'alicyNo.; 6I�9—F
CF,RTII'ICADOf4OF .%EM19yO, FROM WORKERS'
COMPENSATION INSURANCE
ont,seen t aced n r be conmlemd i1'the,noti,is I'll o„r bundrcd dilbvx
($11X1)it le".) '
1 con fy'bid in the pert f the k f which thispermit ed 1
shall n c 1 y off`yD Ln86oubjtox t the W rkcrs
Gn pen. L 1 0 1 1
nppl n
locome If IILIC LICA If B 'k 6th e ,io ', I Pt y :bout,
neromesoh pn+the workers Compensationorprowainns ofthe Laboro-o du oust
' Q O forthwith comply will such Pmvieion,onhix permit shall be deemed revoked.
FmCONS'IRUCfION LENDING AGENCY
C 1 1 hereby athm,Thal there is a construction lending agency for the arlomnce
La G it Inc wink fur which,hle pts ml,x,timed ISm,3097,Civ.QI
a Q lender',Name
Z lender'.,Address
V Q 1 cenify that I have mad this application and eine that the anove information is
E.. correct.I agree to comply with all city and county ordinances and state Lawn miming
Q U tlla
mhnildingaui, uclion. nd hereby nulnoriee repreenlatir—of flux city mentor upon
FWe,mtme.Ine,amied pro,eny ka lnepralin pnpi.a+.
a (We)agrer,o ave,indcnmifyand kcvp hmmlcs dm City of Call agvinvl
(4 liabilities,judgments,costs and expenses which any in any way accrue against said
V Z City in coin uenee of the gr t,6 of thio permit.
AP CANT UNDERSTA ). ANDWILL COMPLY WITH ALL NON-POINT IssuedDate
'E ItEGULA' N5. �j,sol— p0 y'
Itlfe rYn nvvucwntcammnor 7 Data Re-roofs
fcAZAIt DOUS holding
receptor
or handle
Will the applicant nn lumen wilding tea Chapter
store or handle HeaNtws Safety Type of Roof
as de,Sed by the Cupertino Municipal Ctde.Chapter 9.12,mA the Health and Safety
Code,Suction 25532fv)'(
El Ys, 0N All roofs shall be inspected prior to any roofing material being installed.
sort me nppl'Ie:,ol or latarc nuRd'I::gaccopan nse etlaq,moot irdaeicae wl'Ic1, It'TI roof is installed without first obtaining an inspection, I agree to remove
tit hvardeu,air comemivms as detinet by Ise Ray Arca Air t
Quality Mnnagelnn
net! all new materials for inspection. Applicant understands and will comply with
O Yes 0N all non-point source regulations.
1 have rad the h:¢ardoas materials requirements under Chapter 695 of'be
Cnlifnm e Ile nth&Satbty Code.Section,25511.5,25531:md 25534.1 und,adi I thin -
IftheM1ullAingdoc.xnotc�rte� vv :an,uu,that it ix lay re.pinnihllity In nn,i lythe
occupant of the requirctnan soh fi nmst h Inn prior rt,it soan a of a C"lilho a nl
pa"�' - Cam Signature of Applicant Date
f n raraamaaam,tgcn, Dat. All roof coverings to be Class "B" or better
OFFICE