00120133 crry OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
R U I I.DING AODRII.SS: PERMIT No
OWNER'S NA If. tO:J - -1014 AfR _ _1- _ A PLICATIr 1 ATE
PHONE: l AIN1.1 , __ N Y,J - 1 ANIrARY N); n_ 'tb ' OL•N0.
n ao/ ARCIIHF;CrA NGINIiIi1f .. 4 —J J BUILDING PERMI IINFO
�. BLDG BLECI' PLUMB IEC 1
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Z S v LICENS: CONTRACTOR'S neCLAKAIIDN Job Description
L m 1 herehy aflimh that I sem licensed under Provisions of Chapter 9(commencing
= with Section]IIIXp,IU isiu 3of,hu Ihtsinesst d PenfcsionCod•andmy license "
a' � is in lull ocean Ifca
Molt Lice, Gla I.ic.a
LL Dat=��• S CLAI_ REPLACE FURNACE 11305000 INSTALL_ 3 1/2 TI)
ARCHI'I'1iCI"S Up.CLAR I
01ar ae,tananhrplam..Ihan m daspanh, , dv AND 2i'.0 V h_I.ECT. CIRCIIT"I"
licorice O LcenseA Pmlcssianal
OwNERliU11,U13R DIiCLARATION
a 1 herehy option thw I ant csenha(non me C....mr tar's Li¢nse Law file the
C 6 following reason.(section]Ill l 5,Business and liofmsimu Code:Any city or county
D which requires a Formal to con,lm,,,mot,improve.denmbsh,or repair any Wnclure
i3� prions its issuance.also requires the applicant for such permit m ale a signed awenmm
an,If,,,licensed,,arao no he prov l oownf me Cmma,la's Lienee l:Iw(Chapter 9 Sy. Ft. Floor Area Valuation
fumunencing with Section 7100r)lof Division 3 of the Itu,iness and Professions Code)
or that he i,exempt Iherefom and the basis(,,,,he alleged awmption.Any vlolaima
PICO—
or Section 9131.5 by any applicant for a perout subjects the applicant ria civil penalty
of not more than live hundred dollars(550),. APN Number Occupancy Type
C[,;is limner olthe rropeny,or my employees with wages as their sole cmnNusaeon. ote oe $1
will d(, he o 2 1 he or , t I d or olbroll I (See 7014
Bmmr,,anda r - Cade, No Cometwor,C far,does outr,,Iy theca Required In eYClt.ps
fp pearly Wh b Id' Impsd Wo d h kti hxB 31.51h4019. 00 J
owneror gh n: Ply provided ent h et ( tiintendedor
alliance!for sale.Iflite build,G of 1 nen is sold nh n one year of /
'omplmhon,the us aT-Wilder will have the burden of proving than he did not build or
n'p""nfor,ore,rof,ale) 204 — UNDERFLOOR FRAME_
01,as ow net of the property.antexclusively contracting x ith I ecrowd contraclnn,m 301 — ROUGH PI-UMBING
i`consumer the project(sec.]1114,Purolator,and Processions Crate:)The Comrawai .
ia e Law doe ,m npPly In en swam of property who builds or inift thereon, 303 — ROUGH MECHANICAL
and who contracts for such psojeca with a comm hcenvd Farman,hh me
Cnnnaem;.LicaveLow. 304 ROUGW EI ECTRICAI_
01 am cacnlpl under sec.��,11 re PC Int this¢mean
505 — FINAL ELECTRICAL_
Owner WORKER'S COMPENSATION DECLARATION 5177 — FTNAL_ PI. UMBING
I Wrel,y affirm under penoill perjury,one of following declaration%: 506 — FINAL MECHANICAL
0 o haveand will t im;dt CedifiIne it Current m awf.inmou rpt wank,;a 51 It — F I NAI Pl IBI_T C WORKS
Cno,calom, a, Prided a lar by section 3700 n1' the labor Code. for the
peRornsiWe of the work fill which this P.it is issued.
C I have and will muiamin Worker',Conhpeasmlou Insurance,as required by Seellon -
371XI afire LOW,Code,far the peflimnunce of the work for which this pural is
sued,MM'yy W'or/k'er'%Cneinpwen,:niun Insurance currier and Policy numMr are:
Cance:\(
RTIFICATIONOF.sEMPTIO ION INS l (�tRK��t -
COMIIF
aNSAT
(This section nod not be completed if the permit is far one hundred dollars
($100 or lev,.)
1 certify that in the pelf durance of the work Im Which this permit is issued,I
shall not entPloy any M,on in un manner m hazy ry anbiee(to the Workcni
APPlicam '
NOI'ICIi TO object
e :Il,C( making this Certificate W of the Lab o d.youou "Iuld
beutmmm pinup hli Wuch pr Coion,orpau, is pmvuimallbe Luber Cute.you moa
Q 0 fonhwnh comp. fh such Pnrvision<or this q'rmil hall be Jame)revoked.
L
(~ y ChataS",I,aON rce'li NG AGENCY
a ' Iherehy aftimnhis Ibcri Ise.cnmd(See Icndi ngognmy I'unhu Inrlormm�a
of the sad for which this permit in in>ucJ(sec.3097,Ci,C.)
G Lends\Nan¢
7 Z 7 1<nne,.Andrea.,
V Q I funny that I have read this application and stale that the abmva Information
form inn is
;l, hm
u ,l,i agree,o comply wolf ILII city and on ly anland slaws
inun,us m lamlming
Q U misailibut,,urvol and1 b th P f f .- l ths,il,, t Iwo
the SWIs'anuminced P pend foranNetim p rro
es al , indemnify Ik 1 I -,. theCity lC p I gnoul
aid
VJ liabilities judluence,foals aha opo acs which may n cry wily auras altruist said
V z City in conx�yuenee of the 6raming of this permit.
sf)1YCAA1yFNDsAN
1)WILLCOMI'LY WITIIALLNON POINT Issued by: —J®e' t�N7.�ti Ute-' Date ��-21'`•IJ
signnppa,amfeamm,ne nateRe-roofs
IIA%ARDOUS MA1'EItiAL3 DISCI,0SURE
he apphcan[or tonic hu'llldmgt,',igam, ,,an or handle na,:wan,mannan Type of Roof
as defined by the Cupertino Municipal Code Chapter 9.12,and the Health and Safety
Cade.Se lion]5532(al"
❑yes• 0 N All roofs shall be inspected prior to any roofing material being installed.
will the applicant lir(,limn building aatpant use equipment or ties rc%which If a roof is installed without first obtaining an inspection, 1 agree to remove
all,hmadmat air can,:nnimw m� as defined by me Ito)'Arca Air Quality Management
Diarlae all new materials for inspection. Applicant understands and will comply with
O Yes 0 N all non-point source regulations.
1 have read the harardo s materials reyuinal under Chapter 6s95 of file
California Health A Safety Cale.Sections 25505.25533 and 25534.1 understand that
if IIle he ilding dues an,cunuml,nave a mwm,than i,Is my insponsihi lity or a",11,,he
natural of the"firemen,,which must be met prior m iwuonce of a Certificate of
Occupan` _ Signature of Applicant Date
A /
oxen r ram (age.. (—a ate All roof coverings to be Class `B"or better
OFFICE