00100195 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING
11ADDRESS: PERIM F No
IIWNF:12'$p. �.(r ' APPLICATION SUIS DATE
I')
PICKLE ROBEE)E SPNII'AR N VgLCONfROI.NO.
MOO ARCHITECTIENO1NEER: G .�— BUILDING PERMIT'INFO
w p ,-BIANG ELECT PLUMB SU CH
N z =1 1 1_1 1=1
L m d LICENSED CONI RACTOR'S DECLARATION
Job DCticrlp[IOB
O z=, 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
co wills Section"IIXXB of Division 3 of the Business and Professions Code,an lW license
is in full dion
,ae �L S
Ent ¢ Licenx Class l �l� Lica_
�3° n:ne_lo• lTJ•r p_ cnnlraenir�l:uaj� REF'IPE WATER HEATER R' CIRCULAR SYSTEM
ARCH]I CC'S DECLARA[it
1-al to,S 1 understand my plans shall ba uud a,public records
Mz p SIJ Licenced Professional
°'K o OWNIiR-RUILDLR DE.CIARAT ION
m=w 1 hereby uVinn than I an,csermt IYnm the Cnnlemtur X hicmtse Law lir,the
C Z i IIll.ing Ieaon.(Sl 7831.5.Itueini and Professions Code:Any city or county
-SF o which scinow"i pernil to construct,alter,improve,demolish,or repair any nlmctum
war prior to its issuance.u l sur requires the appllema ern such faro t it n It l t.,igloo>IntemenI
that lie is licensed puromma to the poo,ions ofdae Control License luw(Chapter 9 Sy. Ft. Floor Area Valuation
(eunmrereing with Scetion lam)of 0i,ion 3 of the 9minea and Pmessions Code)
or that he is cacntpl brief...and Ilse basil fur lot ullegud c,c,u,ion.Any Andalk
of Section 7831.5 by any applicant fill a person subjects the applicant m a civil penally
,itI..Io.orclhun5uelsmWreddollar,(S5a)1, APN Number - - Oceu pe
❑I,as owner of the property or my employees will,wages as their sole compensation.
will Jre Ilse work.and(lie structure is not intended or odfercd for sale(Sec.7044.
Ilminc„and Profes,ions Code:Bre Comncmr's Licenx Low don,nal appy no an 3F,90 "• equired Inspections
nill
r of property Who build%or imrtovcs thereon.and who dews such work himself
a Ihnmgh his awn iniplo,chowever.t. building
flr such vement is sol stn nal intended er or
affcredfar sale.If.huwver,the buildings improvement if cm is bit within one year of 50 — FINRL PLUMBING ENERGY
nmmgl,dnn,the nwnl,r.huiml,r will novo Bre nmden nr pawing mat lie did or bonds or
improve far pagaax m',ah:f. 506 — GAS TEST
❑1.n,owner II he property,stn exclusively eI meting will,seemed emnmaurs its 507 — FINAL PLUMBING
LWas the project(sec.]844,Business sad Profiessions Gde)The Grmra n is
icense law acres not apply nr an owner of property who Wilds or improves thereon.
and who erntrens for such pruja'0 with o ennnncun(e) limuved pmnum m the /
and who rs I,Iccv, law.
❑1 runt l,aenpt tinder See. ,R A,P C for this recto 3
Owner Dale � c
WORKER'S COMPENSATION DECLARATION VV/
1 heathy affect under penalty of perjury one of the following declarations:
I have and will maintain a Cenidiede of Cotaxnl m xl6imurc for Worker's
ompmtsntion, as provided for by section 37W of the Labor Cade, for the
pednnnunee of lie work dor which this period is issued.
❑1 bate:red will auieain Worker's Campem:ninn Iasnnnee xs reInired by Section
IHXI of the Lahr Code,lin the pedarnatio of Ne work for which this permit is
1 CI oVVrarc:d� NqAer'n Camjwnvtin Insurance c�mandPolicy numh
YCC -
L/
ArIU IPEXIiMI''I(yVPNfA 'O
C'( INSATION
INSURANCE
('this section need nod be eon,lcled if the Ircroil is for one hundred dollars
($I"))I,,los.)
I canify thin in the perforrnuncc of the work for which this permit is sound,1
,tell not c piny any pennn in any manner ,,m m became s.hjcIt m the Worke" _
Compensation Laws of Cahlorniu.Data
Appfcam
NO1 ICE TO APPLICANT If.of sur making this Cenifcem of Iiaerrptiun,You should
become subject do
the Workers Compensation provisions of the Labor Code,you most
Q O ri nhwith comply with such powidoms or mil,,ta it shall hedeemed invoked.
CONSTRUCTION LENDING AGENCY
� ! I hereby afdinu that there is a enn.,too lending agency for she lxrlbmencc
W of the work for which this Permit is issued(See.3097,Clv.CJ
d Q Lender's Nauru
z Lender's Address
V 1 canify that I hnve rend mi,uppllcainu and ante Ilan not ahrrvc information is
ff E. rosea.I ogxc m entudy with all city and county nrdinanem and,,are laws relating
V or building construction,and hereby authorize b,pre,cntmives of this city I,enter ultra
} the otmve-nemioncd tonicity tar im'peetlon purpusas.
F 6s I%,)agree msooc.indemnify and keep hamdms the City of Cupertino against
V] Ilebilitics,ludgimmds,roans lana carcu—which may in any way lateral,ag:dmt.aid
[� Z City in cnnw4uence ill the granting of this pt it.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONBOINT Issued by: �� Date
SOURCE REOUI.AnONS', y'
Signnmre mf ApplicantlContneor Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future huilding nerupard ,are or handle hxmNsas mnadal Type of Roof
as dclined by the Culremm,Municipal Code,Chapter 9.12,and the Health and Safety
Craft.Secti6 12592(a)"
❑Yes ON. All roofs shall be inspected prior to any roofing material being installed.
will the apPlicanl or future buedi lig occupant use equipment or device,wench Ifit roof is installed without first obtaining an inspection, I agree to remove
emit lsaeards.,air con aminants as defiled by the 13ay Area Air Quality Management
m all new materials for inspection. Applicant understands and will comply with
°Yo` 0N all non-point source regulations.
I hove it the haaxntou,snow,uls nquircn ens aider Chapter 0.95 of the
Co tbarria llealth&Safety Coda Section%25505,25533 and 25534.1 undentand Ilett
iflhc bulldingdoe,nu'a ready have a mnunn that it is my m,,mefaiGty to notify the
scent the}gutm ends which nim,b one,prim to iswmnce ill'a Cenlfcate el
°C1�-"y'�J1— Signature of Applicant Date
v
V� � - ao�
Owner or authorized agent Data All roof coverings to be Claws"B" or better
OFFICE