00120149 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING A DDRRSS: M 4, O.
11.15 RQLLCI
.INGD _L_ CT CI.A'EFtT11,0 F9_LA'1PIIgG 001
OWNER'S NAME: 1' r( suit DATE
VL�:EIgIC WfarblE AND Y.UPI(alC VW. 'I 10297 S DEANZfa PLV 12i . 'f �i
PHONE:
�� SANI'IAItY NU. CON'IHOI,No
(408)2(3.3—{dG18
Z-0Z
AIICHITEGVENGINI'.HR: BUILDING PERMIT IND
rq— BLDO HIATC1 IIIdjSf M17 11
LICENSEDCONTRACIOR'S DECLARNHON Job Description
O!,ma_' 1 n M1y i 11 nn that 1 all,licensed.,it p :Of Chapter 9(crenriencle,
).,v,I_Mwnh s t '7001),f D l f the Bu. I d Pn s"o,Code and_mv license Fd3�1 E
yu,¢ 'rose IICf 1_i N
u. Dam_�t.. 'L 7 C...du
tY,7 a. ARCHI'IECr'S DECIARAI )N 1
gN�°—'v 3 1 undcistand my plans%hall be used as public rounds
(OWNER-BUILDER DECLARAnON
1 hi affirm that 1 am exempt from the Comracmrs License law for the
< following reason,(Section]891.5.Business and Profusions Cade:Any city sir county
,a F o which re,p.i res u punnit In comunel.alp,improv..den fish.nr re,...any Itnldure
1�3- prior to it,iuuancc,nBn requirn'Ibe applean,ler.meh pcnnit to lilt nsigncJ,tmcmcm
EEEE that he is licensed da,nentit)the previsions OfnmCmnmclnr,I.mea,eL,oe vChapter9 Sq. Ft. Floor Area Valuation
l aunnica ng with Section AM )of Division 3 of the Business and Prue.s,imv Coil $5000
or that he is e,elnnt Bardeen rust the havi,for the:dleged aamnption.Any violation
of section 70315 by any any ran for a permit subject, it, pre nt In a eiv 11 IaT,k,
Ili not more than live hundred dvBam 6500). 7c�A1P�N Number Occupancy Type
[111.a,nwnet of the Progenor y, ny tail Isitn%ages as their.wile 35934
le conll,ensminn. 008.00
will do the work,nod tire atrnubme o not oreal sir enercd [,it vtlle(Sue.7IM4,
Businc„and Ilede,,,ona code:'Ihe Coatru,bu's License].aw Ams our aPPly Or anRe vire I`n 1s,Rections
r of protardy Who builds or balancers thereon,and who docs such work himself 1 UNDERFLOOR OOR F: 11, YII
or through his own employeesprovided that such improvements are not intended or
olfcred lin sale.II;however,the nundiny Or inproocull is sold within e year: of 301. - F�LAJGF'I I.9_.1.11TIP.T.NG
nplebon.the ownerbuilder%'ill have the burden of Proving that be did an build or
immpmee erparpaseof,ile.). 502 — FINW_ PLUVIB1113 ENLRUY
C I.a,owner of Ne progeny,alp es,1OivrI,eonlramng with reca,ed enntnmmr,to 5107 — FIM— PCIATESING
construct the Pmjcot Bee.9044.Flu, and Prof,, s Code:)The Cel
winter
01n
nd h•law duet not apply,w t t owner ill'u eau y who builds a ..... .toflic
and who ,LivvrO Ino such projects with a n,mrucu,q,)IittnxJ pursuum m the
01Connector,sLicense Law.
❑Iatne,nmpinndelSee. B&rcrmthis ma,alt
Owner Date I /
WORKER'S CON IENSATION DECLARATION Q
1]mash admit under fairly of perjury one of me follow ing declar'utinni: 100,
❑ I have and will Inainmin a Ceninute of Consent In sdGimom for wnrkci,
Compcnvatian, m provided fie by Secfinn 37(10 of the Labor Code, for the
perforlttaace of oro wed lo,wlu,h this Pr....a is is,aed, .
❑I have and will maimain ill',Cnmpre,dion Insurance.as required by Section
3900 of the Labor CnJe.for the perfn olarre of the work file which this pcount is
rtwty.MYW'offkel'Cou1 .tip;- iu Carrier Ja andPolicy nutnherare:
C '(LKf YII�`fi 1 /1,tJ`1�1 Nu.:5�'l.)-7�3Q9_`
/amu, CLRI'IFICATI(IN OF'EXIiMBTION FROM WORK URS
COMI'RNSA'I'ION INSURANCE
(This section need not be completed if the permit is for Inc hundred dollars
0100)or Ics.)
I eenify that in the Ped'uln:unca of the wore fat whish till,per nil i,issued.I
%hall not cirploy any person in an,Inanner,o as u,become subject a,the Workers'
Cumpensaion Lis,ill'California.Date
Applicant
NOTICE FO APPI.ICAN'R It,ulter making Ids Cedlicale of Emniption,you should
beam,subject m the Worker,Cnmpensalion pn,vininit,nr this Labor Cede,you mmol
Q O forb itb comply wish such pnrci,ions,,this pe nn,,hall be deemed revoked.
FZ) CONS'1'RUM ION].FINDING AGENCY
a ' I herchy animt Ibm Ilene 1,a mn,tmaina leading I,n, or We Ierl'nt'nrmcc
of the work far which this permit is is,u.I(Sec.3107.Civ.C.)
2 I<nder',Name
z Lender',Add-„
f..) Q I eenify Nae I have read this a,111ation and ware than the above ink....Orion i,
[z, correct.I agree to comply with all airy and county ordinances and ante laws mlating
Q V to Wilding conructiun.and herby amhorlre representatives of this city u,enter upas
} ry the ono—ini nleneJ jan,rly rernspection purpe,c
Ey y
(We)agree u,save.iadettm�ty and keep harmless he Cly or Cupen int ttgrin,r
lZi liabilities,judgment,,costs and expenses which in,in any way accrue uguina said /+� _�7 `(Yk.+
U r�.Ji City in nm, i 'c tit .ming of this permit. i (/�
AP Nf D IS 'nh)SAND WILL COMPLY WITHALL NON POINT Issuedb Date
( -
SignmurcofAppbcaNContDOU Dam Re-roofs
IIA%AR DOUS l killS RIAfS DISChOS indi
wintile ydau Cllalll,tsirharmipal C, wt„panwen sir nnm he Health; material 'F)/pe of of
as defined by the Cupcninn Municipal Gale.Chapter).1?,Land the Health; Sisley
Code,Section 2553200!
C Ye, 0 N All roofs Shall be inspected prior to any roofing material being installed.
WEB the appheara or famre but ding aeeupell use ega,non,al I,devise,whidt If a roof is installed without first obtaining an inspection, I agree to remove
emir hvardous air conmmimants a,defined by the Bay Area Air Quality hlunapement
District?? all new materials for inspection. Applicant understands and will comply with
�(
El yes 0 N all non-point source regulations.
1 have read he baeai aanerials"trio nems ander Chapter 695 of the
California Berths&Safety core.Sections 8505.25533 and 255N.1 undeme nd that
if the building Joel nal cuncnlly have a tenant,that it i,my respoiOdil'ny to unify the
will of the Ispa "I'll'which natal he stet Aller Io..... se of a C,aillenlc ill'
D 1e' �y Signature of Applicant Date Z� _vim
Owner Or sash It at Dale All roof coverings to be Class "B"or better
OFFICE