00120111CITY OF CUPERTINO
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CONTRACTOR INFORMATION:
BUILDING DIVISION PERMIT
BUILDING ADURESS,
PERMIT NO.
1 q I
F V
11)f71 IsssI711
OWNIiR'S NAME
APPLICATION SOB DATE.
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I I t V
2 TI 0
[ONE
SANITARY NO. CONTROL No
14 J 9 A
ARCIII'fF.(T/F.NGINEER:
BUILDING P17RMII INFO
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BLDG ELECT PLUMB MECU
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I thereby aline that I .,it licensed under prnvisinnsal 'Chapter 9lcunmarocing
ww im Section 71 of Division)of the Business and Profession, Cade.and on, license
full forte and effect,
2 I.in
kcnsv Class U1. M
U Dote Commcmr
'REPLACE 1017) GAL GAS WA"CER HEATER
5ARCHITEC�'SDECLARATION
1 mideas and my plans sil be uvcl as public records
CLicensal Professionnl
OWNER BUILDER DI!CLARxnQN
I NA L E D
I hereby affirm that 1 ate cacntpt frau the Conracmr's Law a Law lin the
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2 fill—in, rcavoo. (Section 703L5, Bmincsr and Professions Code: Any city nr arunty
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o which marines a permit ut construct, aIle(. improve, demolkh' a repair any nro n's
priorInits in,anw,elsu redlines the Uppllci resach permit to file a si6raW statamenl
S(I. t. Floor Area
Valuation
— Nat he is license! preset to the pnwiions di Comment's Liamoe Law (Chapter 9
Leomoencing ,In Scctinn IIIW I of Division 3 of the Business and Professions Cade)
or that he is exempt therefrom and the hasis for [lie alleged eaentption. Any violation
by y opplicam for a pemtit subjects the applicant us a civil pcnahy
of Scotian 70315 un
BUILD11WNumber
OccupinJc�4Tgpe
.1 a,,, me In. fee ]hundred dinars GINX)f
{:
1, as owner of the prj or my employees with wages as their ,,Is co:life nsm ion.
pp IntipeC(1011N
will do the work. Und theetrunure is not imm�dcd nr offered lit, sale (Sec. 7033,
If. me,, and prof e..in., Cade: the Commnuh R.iemnc Ww does noe a,TI, to an
36638003. J'f' Ulrfd
aware of property Who hullds or intpresns thereon, and who dares such work himself
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or through his own employees. provided that such improvements are not intended or
othcrcd lior elle. If, howamri the building or Impnwcment is sold within one yearof
completion. ntea,caner-taimer will haw Ne boNen oflsmving that he di`I not FoOa' or
502 — FINAL PLUMBING ENERGY
improve ter ptnpow nfsale.),
506 — GAS TEST
cr,to
oeMg with licensed eontrum
e pro,y.arte.usi.ely cmm
❑Lits varer of Nrad
ernaruet the pmieet (See. 7we. Ruane., and Prolhsaors Cade:) Ire Contractee'
507 — FINAL PLUMPING
Lice:Ise law docs not apply to an owner of property ,she build, or improves thereon,
had who contacts for such pmjens with a cormwroo,) licensed persutuu Is the
Connenm'x Llcensc Lit.,
❑ I am cumpt under Sec. , B& P C for this mason
Owner Date
' WORKER'S COMPENSATION DECLARATION
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I Iamby allimt under penalty of,iary one of the following dcclamtiom;
I have and will aladoolin a Ceniticmc of Cn lont to ,elf-an .... c for Worker's
ompemmion, as provided for by Section 3704) of the IaIrh Cade, for the
"ed ornrnncosd[lie work forwhich this permit is konal.
❑ I neve Imd will n Inmm Wader's Crmpenearion IoNrano e, as rt0uined by Section
3700 of the Ia1er Cade, for the performance of the work for which Nis permit is
sued. My Workr,'s Co:....r ation Insurance carrier mal Policy number are:
Can Polley No:
CER 'f11aCAl'[ON UP EXEMPR ION FROM WORKERS'
COMPBNSAOON INSIJRANC17
((his section recd on becumpleted it the permit is forme hundred dollars
(51(1010, less.)
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I certify that in the perfuamance of thc work ]or .1jeh this permit is iswcd, I
shall not employ uny persue in any manner so us to hecnnte o do et a the Winker,
Compen.smion Rows of California. Dale
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Applsam
Nfyl'ICCTOAPPLICANT. If, her ori this Cenilicare of Escmptian, you should
became ad,P,,, the Worker', Contpenxin iFnwi ..... of the Labor Caste, you most
forthwith comply with such porekoun. 0r this permit ,hall M deomed revAwd.
A CONSTRUCTION LENDING AGENCY
jI hereby alum that there is a mtranti ion lending ugrmy for the perhnntcow
,
of the work for which this pemtit is issued sec. 3197. Civ. C.)
Lender's Name
Lender's Address
tiIcemify that l hese read this application and smteduo the vhow information is
<owe,l. I ai , c ulply with n11 it, and County nrduanuIr, and smo, law, ralming
to building convmNnn. and hereby matron se rep¢sentaiw, of Nis city it, enter ulna
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�] the aMwe-mentioned prnpcny fo, r,Ps 1 u11 purpo,o,.
4 (We)rare, msnve, indenaifv and keep harmless the City of Cupertino amoral
]] IIahllitic.s. Judgments. coats and espcnecs wluch may In uny w.ay .erre "unxt said
City in coaweauemrt of the grinning of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
Issued by: - Date
y'
SOURCE REGULATIONS.
Re-roofs
Signature of Appicaatrcomramrr Date
HAZARDOUS MAL FRIAI S UISCLOSURE
Will the applicant or future lanal sreeupant,tnmmhandle brear.k,a,rnatedal
Type of Roof
a, ddincd by the Cupertino Mion, pal Cale. Chapter 932, and thc I le:dth and Safety
Calc, Section 25532m)I
0 Ye, Cl No
All roofs shall he inspected prior to any roofing material being installed.
Will hea,hcarlr,ham, handingrecupmttuse c0aiparm:t°rat°°ices`s'IIi,'h
If a roof is installed without first obtaining an inspection, I agree to remove ,
emit hvanloux sur contaminants as defined by the a Bay Area Air Quality Magement
>oho
all new materials for inspection. Applicant understands and will comply with
�Y°° EJNo
all non-point source regulations.
I have recut the haaxrdou, materials requirements under Che rcr 6.95 of the
Cdilbrnin lbahh @ Sab, y Cade. Scass im25505.25533 nod 25594. 1 nudcrxnmd Or,
if the huilding docs not cuncmly have a tenant, that it is my responsibility to notify the
,..Intel of Ne rcauircments which math. be met prior m Issmuea of a Ccnilwalc of
11cvryin".
Signature of Applicant Date
All roof coverings to be Class "B" or better
I
Owner Date
o, inkah led agent
OFFICE