01020113 CITU OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS; PERMIT NO.
OWNER'S NAMIi: APPLICATION SUB DATE
11116LIGAN MARY L. T-R"—c:Tr% 770 r.14FqTNIIT RT 02/21120101
PHONE: SANITARY NO. CONTROL NO.
(408)279-171792
p zQ ARCHITEC IENGINEHR: BUILDING PERMIT INFO
mp BLDG ELEcr PLUMB MECH
jI,ICENSEDCONTRACTOR-S DECLARATION Job Descri tion
y0 1 herehy alfirn that I aif license under provisions ol'Chapter 9 6mmnmbdng - P
FyC with Secllnn'RXdn,,fDivi;.inn Jof In,Beninese end Poofcssions Code.and my license
` -
infall lorecande ea.
_ i.ienwch.._ zo «3_O_ 7L. REPLACE 75, 000 BTU FURNACE
o ca., Data 7=b= enol acmr- �r :5F7717(r
u 3 a is, ARCIII IECT'S DIiCLAR I If
I undemmnd my plans.hall be used a,public arrant, .
w615p O Lice ed Ike&s,ionul
co OWNEWBacrapt o m the ContractN
I hereby.(Sens that I ant ebusin tram the Cession, a License law fur the
followC Y mooch ng Inn,a (SectionIt)..31.5. .alb,ss and pronc.de inn..Calc:Any city or county
12 o whieM1 reyuirc,n Pcnnll b,anr,lmcl,aper.in;pnre.Ae;unlieM1,or -,air any structure
re
or
3w pror to its issurence,also"Lifes the applicant far uchpermit I Ie a signed saricaricift
that he is licensedp l or lie From I the Conato,or,I < ].it,charter Sq. Ft. Floor Area IDall
(commencing with Section Iapt of Division f ofin Business and P fe%i n-Cook)
or that lie\ `emptdirect nm and da basis rIhe U lcgil aoa...pr , Ary ,I:(oo
of Section 7(111 S by any applicant for a permit subjecr the applicam m a civil penalty
ofnntn,re loan Foe hundreddollm, still, APN Number Occupancy Tfpc
❑h as owner of the property,or my employees with wages as Ihear sole compensation,
will Jo on,work,and the rarembe is not intended nr offered for sole(Sec.7W4, 36153t t
00
Business and Professions CrdContractor s License ladoes u
Laos ds not apply ,an e
c: 'fhc quired Inspections
orwar,ol pmpeny Who b,dlds sir impmve,Ihvmon,and sono dues such week himself
or through his own employeesprovided that such improvements arc not intended or
aPered forme,I,however,tire beildmgo mph, ent s.rld within rare year of 204 — UNDERFLOOR FRAME
icompletion,the nwnerler xallhave the naeeen`ofpmvine that he did not(wile or 301 — ROUGH PLUMBING
mprove for pmpa.e or.alal.
Cl L or,ower of he pro"t,mr,s,clasi,cly contracting wltl,reeaed eorbaron,m 303 — ROUGH MECHANICAL
,namcthe protect(See 7(44.na.sine..and Profcs.ion,Cade:IMecomeacmr, 304 — ROUGH ELECTRICAL
-icenx law due,nal apply u,um owner of pmpeny who build.,sir improve,rNbrou.
all war canlrnet,, rat Inch projects with it rantrammp)licensed pursuant ,,rhe 505 — FINAL ELECTRICAL
'mars r,License Law.
❑I art,exempt nn le,Sec. .Ha P C for thi—ra'`°n 507 — FINAL. PLUMBING
Owner Dane 508 — FINAL MECHANICAL
WORKER'S COMPENSATION DECLARNFION
I hereby amort under penalty of petjuD'one of the fallowing declaration,: 514 — FINAL PUBLIC WORKS
O 1 have :mI will arentuin a Ccrtilie:ne of Comorm Io selpinmre for Walker:
Compensation, as provided liar by Section 7700 of the labor Cade for the
pedornun r of me work for which Ilii,paratil is owed.
❑I have and will maintain Wurkcr'.,Cnmpcmwinn huurancc.;a required by Seoion
JFp of he Inbar Cook,for the performance of the work for which this permit is
issued MyyWWrrk
Io_erl,, m
Copensation Insurance varier and policy hander e:
CaeyIm
P—I k�k�a 0 1 Policy No.:
CTFI'I IICOrION OF EOF EXEMPTION FROM WORK LRS'
COMPENSATION INSURANCE
fl*is wetion need not are,completed if the parted is for one hundred dollars
($1001 or le—)
Lenity Thal in the perfnnnanm et the work for which Ilii,permit is isxual,1
shall not employ any parson in any entrance a,m Io her subject to the Worker:
Compemmicn Ltw,of Culilor is.Dam
nppbeant
NOTICE 10APPLICAN'1'.It, her making on,Qrtificatenl Estate, 1.you should
become snhjeat to be Wnrkei s Con,peoratiun provisions of the Labor Coda,you must
0 O hmbwim comply with such pmvi,iun,or his permit,hull be decried arvoked.
F N-aCONSTRUCIION LENDING AGENCY
I hereby of!ruthat them is a conarred n lending agency lin the"For m rs,
Ord of the wed for which his permit is issued(See 3W7.For.C.)
Q lender,Name
D z Lrndcr'I A,Idresn
U 0 1 certify that I base acrd this applicntinn and state that the above infnrat is
la. [,. emor 1 agar[m comlly with all city and county so tribunes and store laws relaJng
Q U In huilding constraoinn,bad herehy authorw representatives ofihi,.city to enter blast
the abrvcmcrumbed pmpeny liar impaction proposal.
p. (We)agree to save.indemorhynnd keep harmlcn,the City rd Cupenlnnngainst
h liabilities,judgments,cosi,and e,penses wbch may in any or,accrue against said
t, Z City in con,eyusere of the gramin,of oris per it,
APPLICANT UNDERSTANDS ANI oILL'COMPLY AWITH ALL NON-POINT y'
IsSued by: Dale
SOUPEGUI,ATIONn. —t / d 4��� I
Signature m nppecam tout,r Dam Re-roofs
Ian applicant oRD0 eS MATERInLS DISCLOSURE
Will y f rcups; at future Wilding C cecupam nater 2,saddle ForHeaAoan S aiw Type of Roof Cut
by the .12ho 1nu nnictpel Cadc,CM1upmr 9.12.:nW the Health and Safety
Coda Secllnn 25512(u)?
❑Yes No All roofs shall be inspected prior to any rooting material being installed.
Will the appfteant or ware brddbtgo,,,,ub rose can no a;drain,wl,i,h If a roof is installed without first obtaining an inspection, 1 agree to remove
•mil hranbdaus air commit Ica.defined by the Bay Area Air Quality Management
ir.Idat7 - all new materials for inspection. Applicant understands and will comply with
ora, No all non-point source regulations.
1 have read the harrduae mumrials beerrinvolearS under CM1upmr 6.95 of the
California Health k Srfcn Cadc Seeders 25505,LS513 and 255y1.I undcntund Thal
it the holdingdoes riot eurmndy have a tenant,thus II is my esponsibilily u,nullfy the
ocet of the oct,mnnene,son' o usI ria and prior or issuance of er cenifieme of
"by
" "or, Signature of Applicant Date
2-�/-D�
Owmcrar aaomriacd agate Dntc All roof coverings to be Class "B"or better
OFFICE