00070067 CITY OF CUPERTINO
BUu.DINC T CONTRACTOR INFORMATION:
HOLDING ADDRESS: PERMITNO.
OW'NER'S NAME. APPI.ICAI'ION SUR P\1
PHONE: SANITARY NO. CONI ROL NO.
BUILDING PERMIT INFO
-0�p ARCHITECfzENGINr:13Ro IILDG ELECT I'LUMH MECH
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LICENSIiU CONTRACTOR'S UECLARA'I'ION
z 5 1 hereby rt! mal I aam ueeno l anaut aionnofChat , g UPGRADE TOJob Rech jDn PANEL
o y- y u pnd Chaplin (amtnmmin r-
^Cumi with fall ioreund ar Divi,lnn3nrthe l3usincc.luul l'rol'cxsions cads.and mYlicvnm
Ls III I11II li,rcc and effect.
%O uyrelu License Clans Lie.N
Date Contractor
3 a G ARCHITECT'S DECLARATION -
f-=of g 1 unde smnd my plans,hull be va d as public ra nNa
Eat
¢5 Licensed Pralcsnianul
iao�
A OWNER.BUILDER DECL Colorado,
W=' I herchy uffnn teat 1 nm exempt lions the QnnnadC n .Anyc city
o o, the '
Which lig a a(Sutton 70.11 5.Rnnlnc, osis I'fnlo s Crede:Any city 'I tnty
Z O which,squirm npermit ac linaavet Nter,dRa,ve,de e...m ,ur repair Imy sbedart t
tteiy3 Ra "'m'hemslicensed mrlmrequires he pookillesolorsuchpeca,, file ueLaw,(aad Catemem
- tlmntnei..HeraedpnraannuomeHra�iaanaonnecamt,na,a.kenneww(chuprer') Sq. FL Floor Area Value Ion
leommencinF with Section 7000)of Do man 3 of Oe Rosins and Pmfcsaimi Code)
or that he is exempt therefrom and the basis for the alleged exemption.Any violation
of Section 7031.5 by any applicant for a permit subject the applicant to a civil penally ) ,
om
fnotorcmunfirchundrcddull...(S50% AFN Occupancy Type
Ir f m prop.ry Y nPmy th g: pnsuuon
willl J d the k J the 't 't is not antentled 11 te d for.-1l Soc.71144 —
Bnv d P f sio C I 'll Cmn t I w 1: t pply 11 m q I e' s
wrierufptaperyWhohada.or'tmpiovcsmenton.ariawbodoe,.rashworkranaelr 501.. — ENERGY
ur thmuah hi,awn nnpoyec...I,n,,id d(bat such implbvmncnx are rani leaded or
offered ror valea;howeve, It,building or tnVmrovetaent in nom within one year of 505 — FINAL ELECTRICAL
completion,ate mvncr-builder will have the burden arpmving that he did ant build ser .
mprove rat pmposo)I sale.)
01,a,am nor of the property.am esclavvety contracting x int licensed contractor,at
Lnnstruct the project,see.70144.Business and Profen.ionn Code:)The contractor's
icense Law does not appy to an owner of property woo baudx or improves thereon,
Ind who contracts for such pnmject,with a ennmeaona)licensed punuunt to the
Cunlclo"Liters,Lux.
❑1:1111 a%etnpl ander Se' _ _ .H h P C tot this n.tit /
awl re —o
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WORKER'S COMPENSATION CLAN,T N
1 hereby affirm under.maty of perjury no of the following declamations: to
0 1 have and will maintain a Cenificure of Consent m self-insure for W'orker's - v
Compensation, as provided for by Section 371X1 of the Luber Code, for the -
perfamm.at the xnrk for which this permit in issued.
01 lane and will Inuialula Wnrkcr's Compennmlon In..ufnme,ns required by Seution
3700 it die,L,l r Cada,lo, the pedonlmale dlbe wml,far which It.permit Ix
issued.My Worker's Co hast mann Insurance currier Ind Policy Immher are:
Carrier: Policy No.:
CERTIFICA'1'ION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -.
(This section need not he completed if the permit is far one hundred dollar
IS 100)or It,,.)
I cavity teat in the performance of the work for which this permit in issued,I
shall not cmpin),any person In tiny manncr,o lu m bean¢subject In the Workers
Cooq,cmation Laws of Ccli En 11 In Oats
nppdamt
NOTICE TO APPLICANT Ili Wo,,making this Certificate of Esctnption you should
nccnn a subject in,the Workers Compensation provision,oT lee labor Coca I'm Inua
2 fonhwith empty with such It Won,or this permit shall an deemed revoked.
F .N.I CONSTRUCTION LENDING lending
AGENCY
Ci } I hereby affirm this there mss construction lending agency for the performance
W of the work forme which this permit is ii.nN($ec.3119].Civ.C.)
5 A Le tier's Nunn
� L Leader's nddmns
U O I calmly amt I have rend this npplicatin l and state thus the Ibove in min pion Is
t+s F" a neat.I agree to cnntply wilh all city and ,,only ordlnaae,,and nate laws relating _
C V mhuilding con.amction,and bomb),mahnrirc rcprcwntuti.,sol this ciym anter upor
} R7 me above-mentioned prapeny for ins,xction Furrows.
E.. a OVe)agree to an indemnify and keep harmless the City ofCuperimagainst
Vi liabilities.judgment,coot and asp nwo which may in any way accrue against,aid
V Z City in umequence til the granting til permit. /✓ /'
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: ( C..- Date -0v
SOURCE REGULATIONS, y'
Signuutre ser Apphcllla/Coile alar On, Re-roofs -
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or tanta Mddbs'keapalmt store ser handle heamdo..material Type of Roof
as demand by the Ca,mao nfuni ,a l Code.Charter 9.12,and the Health and Story
Cade,SeeYen 25532(.1^
O0N
All roofs shall be inspected prior to .my Fooling material being installed.
Will the applicant or future nailding owcupant use cgaipmem o:device,which If a roof is installed without first obtaining an inspection, 1 agree to remove
unit hazardous air cOnnaminnnt..aa dainW by the Hay Arca Air could,Managemem
Dlariarr all new materials for inspection. Applicant understands and will comply with
Cl Yes C3 N. all non-point source regulations.
1 have need the Luzanlnus nm acted,req.irenteuln Older Cli 6.95 oT the -
Californiu Ifeulth A Safcty Codc,Sections 25505,2553, and 25534.1 undermmtd that
ifma buimingdoesnotcurrcntlylime.1enum,thmeist v re.pnns,olitytonoldythe
ncupent of the requla'nems whiC rest be mel prior, In\s ce of a CCnificute of
Occapane` Signature of Applicant Date
0 er or authorize, seg,+m [).to All roof coverings to be Class "B" or better