01010123 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
I BUILDING A DURESS: r PERMIT NO.
OWNER'S NAM17: AI'i'I.ICAI'ION SUR DATE
S'. 01/30/P?PJC),I.
PHONE: m SAN]EARY NO. CONTROL NO.
Ix
X00 ARCHI'THCUINGINHIR' BUILDING PERMIT INTO
R
I11.UG ELECT' 1'LUMH MICH
Nab LI CI I-1 I'_I
F N LICENSED CONTRACTOR'S DECLARATION Job Description
Z_C I hereby
uflnon Inut 1 am licenmd under pruviminm of Chapter 9(commencing
FSC . with Section700(hof Divi,i.a Sot the Hueine,,and Profeesionv Code Lord my license
n full fora,andeffect.
w i`.iCcaw Cl:r,. 1d1.N 14..31-ACE WATIHM I-UPM-R
0 Dole Cnnlraalnr
a 3 u rat ARCHI'IE I
un 'S DECLARAIDON
C=O; I dersand my Plans,hall use
he d ar puhbe oc,oNv
a
q c,
co. Licensed Professional
Ol4NER.HUILDER DECLARNHON
W Lot 1 hereempt hy.Ilion thin I um exfrom the Comrunor's License Law for the
following reason.(Section 90115.Hu,inos,and Pndcsslons Clic Any city or county
wbvh oc,uire,a'warnit s I I Ilcr J limn ou y sem at re
es,� Priort t Iw 1 I tic I i p lieor FILl U,i,ried,lananarna
'hath IP ,u l or the P n l the C aa'%U n W (Chapter 1) Sq. Ft. FloorArea Valuation
Innnnsncag with Section 91)(M11 of Divrsion J of the Iboinms Lord Profession,Cole)
or that be is exempt therefson and the Iasis fur the alleged c,citrption.Any violation ce
of Section 7131.5 by any oMha,a for a permit subjects the applicant to a civil Penalty
of note thar lire hundred dollars($500). APN Number Occupancy Type
❑I,.,owner of the Trnpeny,or illy employees w ilh wages as their vole colnscrsminr. - •9
080
Will do the wad,and the,huaure i,Loota
inJo-1 or olIia sale ale(Sec.9044,
lie, uuI Plot o s Code:ar
It'Chi rant,L&mue Low de,no,apply ,,: Required Inspections
ow r rr of property Will)Will)hnild,or xnprovesthereon,and who docs such work hinnelf
r through his own entpinyee,.provided that sum bu,swemerax are no,intended or 502 — FINAL PURTICiING F1IM3y
offered for sale.IL however.the building or itnprnvetnent is sold within one year of
complction,the owner-builder will have the hurden of Proving that he did not build or 506 — GAS TLST
improve fm purpose of vale.).
❑I,a.owner of the property,an exdusi,, , dProaingwho l.e) [II C contractorsuncom C'�OAL.�6
FI.IJPo_ Fol-l-I LING
Banta tlw poeseal(Sae. (,I lint f:mJ i' , It,,I ILK or LIP .I, ntcmr'v r ,V
tod who
Law does Bol.puc In an owner ill'pngsny who builds s Improv a tlmreon. _
and who Connector
Licanv Ibr such Pnrjedx with n wmmaurfq IiacnmcJ pnrxmm m the
01 antcalla.i,endeLSee OCT .0 8 2001
❑1 am cxcmpt under Stt, .❑.t P C for his rcuam
Omer Dae
WORKER'S COMMENSAL ION DECLARN'ION
BUILDING
1 lately uftimr Hadar penally of ,,,ill,ow offal kolowing dedaradonm:
❑ 1 have and will neutrino a Crtrlificn,c of Cnmenl er wlGiraure for Worker's
Compemauon, as provided for by Section 17191 of the Labor Cade for the
pefformana of the work for which this Permit is issued.
O 1 haw and will mninlnin Worker'.CannPenction Insurance,as required by Second
TIIM)of the IaMa Code.for the perfnrn:mce of the work for which this permit is
issued,My Worker's C'ontpensati,n Insurance Carrier and Policy number Ire:
Cnrrico Palley No.:
CIR I[FICATION OF ESEM]"ION FROM WORKERS*
COMPENSATION INSURANCE
(This senion need not he cornplened if the pcnnit is lir one hundred dollars
o 1w)or los.)
I certify that In the performance of the work for which his feral,is issunl,1
shall nor cotpfoy why pax ally a ,so:n or hecomI,object to the Wod,ls
C'omper.aion Lawsol Cliffornill.Lyre
Appuaam
NOTICE Us APPLICANT If,after making this Certifhcme of Exanption,you should
7 Menthe while, rhe Workcrs Co ap,rsation Provisions of rhe hbr Cada you oast
QQ forth,;m comply with such provisions or,his permit,hill the de....J rcvokcd.
Fr^ CONSTRUCTION LENDING AGENCY
a I hesby efula that there is a ttmumelion lending agency 1'or the pvrf oroance
La ol'the work for which This perodr is issued(Sec.309).Co,.Cd
O. Q Lender',Nuns
.7. 7 LerrI Address.
U O 1 cerify that I have read this application and male that the above inforeation is
Ls, [.. correct,I agree In comply with all city and county ordinance,and state lawn relating
to heilding comwaion.and hereby amhorve representatives of this city to enter uplrn
the abne.mer alr,d property or'rmpcnion purpose..
(We)egret,msrrve,mdanatdy nal keel h.ndas.the Ci ly of CoIndiso against
Lr m IiabiliGd,wdsronua.msla and caparoes whim only it my way a Loa aunk o6d
U City in consnptnrvc of rive grunting of prise permir.
SOURCAN CUDERSTgNDS AND WILL COMPLY WI'FII ALI.NON-POINT Issued by: Date
Signature of APpliaaMCourracmr Date Re-roofs
HAZARDOUS MMERIAI S DISCLOSURE
Will the applicant or future building accup:nnme or handle hazardous manrell Type of Roof
as darned by the Cupstino Mtulei,,I Code,Chapter 9.12,eaI IIs Heahh i d Safe,,
CLIC.Scelion 255320x1:
❑Ye, No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future biding lccupant use cquiprncen(it devices which If a roof is installed Without first Obtaining an inspection, I agree to remove
emit u-nal air continuation,as defined by the Hay Arta Air evil M.naecmeHa
Dimtrbr all new materials for inspection. Applicant understands and will comply with
ore.. 0 N all non-point Source regulations.
have m:al the hw rdorr.mmvrial.v r,grdrern,ms Irxr let Cn:tprcr 6.95 of lire
Callomiu i Icahn.G Safety Code,Set, L,25505,25513aad25534.1 underxl:ndrhal
if the building docs nor cmrerlly have a Temno,that it is illy rmpooi olily to unity the
cufalt of rhe re9uiremenrc which xnm,be tire,prior Loh issuance of a Cerificate if
°Cupant. , Signature of Applicant Date
OwnHaor autherved u,cat Dale IAll roof coverings to be Class "B" or better
OFFICE.