00060085 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING A[V8150 PENDERGAS'T AVE JUST WATER HEATERS I '�IIND0006@085
OWNER NAIKE MARKET 1764 NATIONAL AVE APPLICA!
PHON[: SANITARY NO. CONTROI,NO.
(510) 293-9901
M z Z ARCHITECDENGWEER: BUILDING PERMIT INFO
O BLOC I;LECI' PLUMB MECH
I� Irl Irl
y¢
0 S Y a II to''NSIi ant
under s DEQLARAChapl Job Description
O —O I hereby nllirm[hat I am of the B under pnd profs of ns Code.Remymneing
J with semloneirld of Division me Business and professions Ctde,and my licaou WATER HEATER
z ¢ [)in tsll(nice and Glia:(.
lame class Lim.x
%% O Dae CarmarcuSDECLAr
m 3 a In AHChall be use as
recd N
C O 1 unticrUanJ my plans shall M uttJ as puhlic records
as
ia p O Liacnced I'mlessinnnl
°• OWNER-BUILDER DECLARATION
w I hereby i fl na that 1 amlamp[(rain he Con.nemw r'.License lafor(he
(allowing reason.(Seat im19131.5�Ilusincus and Profession,Gale Any city arcounty
Y Y o which requires a peril to construct,alter,improve,demnli.sh,or repmr any structure
i 5 aI
aI pri t [ L 4 M1 ppb' f hpe a fl m
signed
'bar he :dpursuant t top fm Contractor L Li (Cnainery Sy. Ft. Floor Area Valu•u'o�t�
(crt nine.. gw'ih Secular 7111%BofDivii nlrltheBa to andlt f..' isCdel
or mat he is exankin(herefract and the hok for the alleged enetntaiml Any vialmion `a"r
of Section 7031.5 by any applicant ter a permit subjects the applicant to a civil penally
of tint mire mlive ve handed dinars($100) APN Number Occupancy Type
❑ ...... fin property ye tphyee. m ..sash 1 c ni:cusatnn 7527031. 00
will do Illk and he moolur.is I 1 1.1 1 1 it totaled 1' (Sec.7044
Business andP m,,mrs Cs. IT contractor L La d t pd, ,,an Required Inspections
fl PenyWn num ,mva,m awn .ed . h rknmself 502 — FINAL PLUMBING ENERGY
I,,hreugb his own employe.......sired Ihw such in,.evencnts are nal pleaded or
oBJted for sale.If,huwcvcr,the Wilding or improvement is sold within one year(if 506 — GAS TEST
iomfiction.the owner-budder will have the burden of proving that he did not build or
mprove liar purpose III sal ,) 507 — FINAL PLUMBING
❑Las awncrof the propcny.am exclusively comractmg wire hanxd contractors to
m.loo pha,prujcn(Sce.7(r14.Buless and Protessiunal
I,Cc)The Conor oo,'s
Licanse Low dins not apply to as aware,of p,operm who builds or improves thereon.
and who contracts for such projects with a contna00%)licensed pursuant to the
Cn an,aemr'x License Law.
❑1 tun exempt under Sec. .B g P C ter his reason
Owner Date
WORKER'S C'OMPBNSAIION DECLARA'I ION
1 hereby uflirm under Penalty of perjury one of the billowing declnnJnns:
❑ 1 have and will maintain a Carificntc of Consent ,,self-insure for Worker's
Compensation, as provided for by Section 3710 of the labor Cada, for the
ferinrovime it Phe wad to,which(his pamtit is issued.
❑1 have and will:le intain Worker's Contlunsmion Insurance,as required by Section
391N)or(bu Labor CuJc,for the perlbnnuna or the work Car which phis Penni(Is '
.sued.My Wa oars Compcnsalin I Insnnnce carrier and Policy number arcs
Carrier: Policy No.:
CERrIIICAOON 017 EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need no(be completed if the permit is for one hundred dollar
(51War loss.)
1 o,cif,Wul in Ile parfnninnocent M1e work for which this permit is issued.I
shall not employ any parson in any manner so as to become subject it;the Wmkas
Conipausa'mn Laws of Uflonia.[)all
Applicant -
NOTICE TO APPLICAMC if,after i.king this Certificate of Esunption.You should
become n,,hj,lt m(b.Worker's Contpensnl inn provisions nl'Ill Lowe Code,you nater
Q Q fordo,ire comply wish such provisions or phis Perini(shall M1e declined revoked
,z^� rte. CONSTRUCTION LENDING AGENCY -
� , I hemby ati rut den there is a consWainn lending agaey or he p:rfnrinuncc
or he walk far x'hich this Peril is I....it(Sec.3099.Civ,Cf
C Lander'.Num.
7 2 Lender's Address ,
U 1 cenify that I have mad this application and state that the above orientation is
W t„t torten.I agree it,comply with all city and.ennty onfintmca and spill laws minting
U tobuilding com(tnnion.and hereby authorize repnserouses of this city tri enter upon
sI' the ebove-ntentionod property for inspection purposes.
Fa d Om)agree ulInol.lndnnnily and kcup orioles'till City et Captain"upuina
Z) liabilities.judgments,coos and eapeoses which only in any way accrue against.said
U city in nmaequunce of the .air,of This I+ri,.
APPLICANT UNDBRS'1'ANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. y'
S'.snatntc ifAlIpRea.uc..itvan..iData Re-roofs
HAZARDOUS MAI Y.RIAI S DISCLOSURE
sunt he applicant or far..building o¢uPunt store or handle hazardous material Type of Roof
as defined by(hc Cupertino Municipal Cialc.chains,9.12.call the Hearth and&rely
Cidc-Section 25532(x)"
Cl yes 0"o All roofs shall be inspected prior to any roofing material being installed.
Will the appli,an(or future building tecnpon[use aquipman er Aevices which If a roof is installed without first obtaining an inspection, I agree to remove
tit hazardous air contaminants as defined by the Bay Arca Air quality Management
,i.od"? all new materials for inspection. Applicant understands and will comply with
0 yes [DNo all non-point source regulations.
I hall mad(he hwaminls ntaeriule requircmenD under Chapter 6.95 of Bre
California Health a Solely Ccrde,Sell ons255(15.25533 and 25534,I undasmnd(bat
if the building docs not cmrcmly have a tenant,that it is my resrymsibiloy to notify the
eapam of the mquiremmnts xbich must be tire[prior to issuance Ida Cer ilicnn of
Occupivay.
Signature of Applicant Date
Uwaeaon,au(ltari,adagxnt Date All roof coverings to be Class `iB"or better
OFFICE
CUPERTINO PERMIT NO.
G DIVISION PERMIT CONTRACTOR INFORMATION: �6(„bb gas
BUILDING ADDRESS: /j� ��1^� `///�Ll-.s�i+ ��//V
��Q///�e�f �/f- �(�,�///� (/eQ�7 7U�jJ /n1///�]LJL///fin//�� LG ✓)vp! ./N SANITARY NO. APPLICATION SUBMfITALDAT
OWNER'S NA rQ/ L //fY / ,_•J /�//V[/r �YL'
NIC CONTROLM
.Nr.: 1 G� 252. 10230 #/ /.t/�'�! 6� 9/,lys °
ARCHITECTIENGINEER 1 /fn BULDING'PERMIT INFO
00
wZ
LICENSED CONTRACTOR'S DECLARATION
p i= 1 hereby,M.Nn I Can licensed under proviumn of Ch,pier 9(mistreating Job Description
u with Section7000)orDiv'si0n3ot BosimsaM fmsip Code a mylia is �o /_� L.� j`•
z W< in full force
W eReet
IAcenu e
uyl 3 u y Date Conumwr
h a O Q ARCHITECTS DEC TI N
5 v� 1 undam acd my Plans"I W used u myk rewNs
NM2E
w S r Li=rnmd Pmfesaioel
c vl a OWNER-BUDDER DECLARATION
z a 1 hereby.(fico Nan 1 am easmp from Ne con[rmmts c:Any c Law(m the
x O
F.Ilawri.g Ireton. er ii t 703 LA".aircss end Prafotiana Cade:Any city .county
w3� wnirnngrim.Dmnitwaamw=n.NaeihlpeovedemmiM,Mmpaifanr.w=carr Sq. Ft. Floor Area Valuatiojit
that
isss censerFarman,
armarequhet sed Apices of the AMM1PemNwimare Law
9
Nat be is licensed Pafsuamw Ne provisions of the Contrxw/a Licrnse Law(C oder r 0`/✓- f/
that he I.AAgwlth Section T000)oo,basis far of throw exe Moon.An,onsCndc)m APN u r Occupancy Type
Ws he is comp[any a m And Ne brit for the alleged exemption.Any violation of ,) // P Y YP
Section7031.5than by any appWmt for(a permit subjects dte applium to a civil patty of
nm mom than rise hundred dollen y cmpl
idodie Mrar NepoPsny,ae my employer with wagef for We
compensation. Required Inspections
will do Nework and Nasacortranm immded Law dnfor A(Sm.loan wnenof
,rd Professions Code:TM Contractor License Law does era apply w rn wrcr of
his o nY wed Wilds w improver t inch i pr w W dm ruck work deed.,a through
his own emDloyccs,Provided Net such improvements art not intended Or ofi<red for
ole If,however,the Wilding an Improvement it will within oM yor ofmprow for
ower-Wilder will have the Wrden of proving than M1e did nm Wild m improve for pw- /
pass of ole.). �gf�
1,,s owner of the properly,Can exclusively contracting with licensed contractors in w^
mmwcn the project(Sm.7044,Business and Professions Cade:)1Te Contemwh
lawtdoer apply jla an of peapmy who Wilds as n Numn..Lrria-
whocantawlsfa,such pmma with acantractes)licensed prtuTombadon Canumm/t
Licenselawsee.
O/O
Iamcxemr
O
Owner Due
WORKERS COMPENSATION DECLARATION
1 hereby affirm underpeaslry,of perjury oM of the following declarations:
1 have andwill maim am n Cenifcale afComrnr m self.imure far Workee.Campen-
sation,as Provided for by Smooth 3700 of Nt
e Labor Code.far the a fomume of the
york fm which Nis permit is issued.
xf3pf�{+1 1 have and will mainnan Warkds Compensation Insurance,o requited by Scotian
Wof the tabor Cade.far-rheprfonence of dw a work for which this Permit Ice iss 1.
My Wohcye)C�� jug e<ertier candy Ne,mm�bez 2 0&d Jd
Carder. (�i Policy No.: (/`SC/CU
CERTIFICATE OF EXEMPTION FROM WORI(ERS'
COMPENSATION INSURANCE
(This.van dead.W completed if Ne Ferritin Boone hundred dollen(5100)
or leu.)
I cmify Nor in the perfotmu¢eofile work for whichthia Penson is issued,l shall
m employ any persen in any manor An as in becan a subjmr to tla Workeri Compn-
sation laws of California.Date
Applicant
NOTICE TO APPLICANT:If.afar malting Nis Certificate of E,empdon,you should
become subjeet to An,Wos .Compenution pmviriont of the tabor Code,gam muss
forthwith comply with such provisions m this permit"I W doomed masked.
CONSTRUCTION LENDING AGENCY
QIherebI.T..lNt there is a conHromon leading agency fm the psef0ernsnee of
work for which Nis Permit is issued(Sm.3097,Civ.C.)
Ew4 Leader,Name
} Iandre,Addrexs
[al I unify this 1 have sad Nis application and AMC Nat the above Information is
m.,I Agree to comply with all city end county otdi...lea and sthe laws sluing 10
w7 7. building communion.and hereby auNodze Mpresenasives Ofthis city to enter upon the
U abovcmemioned p rainy for inspevan proposes.
k. E,. (We)agree to use.indemnity and kap Nrmleas the city of eupmioo against
t.7 liabilities,judgment,cons and expenses which may in any way seems against said City
} W in consequence of she granting of thi permit.
[� L APPLICANTU' ERSTAND' ')WI I.I.COMPLY WITH AIA.NON-NII)T
U Z SOURCE tB
of Apf-antAO mr.cto Date
HAZARDOUS MATERIALS DISCLOSURE
Will tle,.,Iicanl or from Wilding....Arae or handle hawdoua material Re-roofs
&fined by she Cupnina Mani=ipal Code,Chapter 9,12,Caul the Had,and Safety T e Of Roof
Cade Smbon x5532(,1+ YP
❑Yea
Will the appli'so or wabullding occupant use equipment or devices which All roots shall be inspected prior to any roofing material being
emit bacallo s air continuations As defined by the Bay Asia Ah Quality Management installed. If a roof is Installed without first obtaining an inspection
coronet? I a ree to remove all new aterials for inspection. Applicant
[3 Y. ho
Iluve read the barony,matenala mgritermamdrr�h.pr,695 of the Gari- un a an nd wil ply with all non point source r gulations.
n (orris Health B Safety Cade,Sections 25503.25533 end 25530.1 understand that if dic SD
Wildingdm cunentlylavcatenam Nhsitismynsponsibilirywnaify Nemmv t
ofdwrega' hicM1 mull be pdorwiaroanceofa Cedlficme f
S a[tFe of Applican N3 Date
0 r u .gent
All roof coverings to be Class"B"or better
OFFICE