05020159 CITY OF CUPERTINO tx
BUILDING DIVISION PERMIT CO NTRAGTQRffNFQRMATION
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BUILDING ADDRESS: SUM' S CONSTRUCTION PERMITNO05020159
OWNER'S NAME: PERMIT L95UR DATE
147 PqTHPR Avg
196/2�
E; SANITARY O. O OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
OELECT PLO MECH
LICENSED CONTRACTOR'S DECLARATION Job Description
1 hemby affirm that 1 am licensed under provisions of Chapter 9(commencing with Section 7IXIU)ofDivWen Sof Na Business Profcuinns Code.entl mylieenmh
in full
to.and effect.
p��nmClean _�n lyy/ � rG�1 ADD 660 ' (LIV. / 2 BATH/1 BED) &
tggtt� ARCHITECTS DECLARATION REMODEL BATH] KTICHEN
I understand my plans shall he used as public mmNs
3 Licensed Professional
OWNER-BUILDER DECLARATION
I I ream affirm on 1 am,Bumps from Ills ConvmtCo :My c Lew for the
Ra O following moon.Section 7fD13,Business and Profession Code:Any city or county
$ which requires a Permit to Cowruct,eller.improve,demolish.or mpai,any chromium
F�;^ prior he its issuance.Alm requires the applicant forsuch ischii u rile a signed statement
z€< that hcislicensed pussuantin the prevision of heContracmril.icense Law(Chapter 9 Sq.Ft. Floor Area ValuOag000
p0 (commencing with Section 7000)Of Division 3 of NC Business and Promalons Code)or 4
a$ that he is esempl Nemfrom and the basis for the alleged exemption.Any violation of
Section 7D31.5 by any applicant for a permit mbjeets the applicant in a civil penally of APN Number Occupancy Type
not mom than fns hundred doled($5007.
❑1,u own Clubs Property.or toy unployces wile wages as daub auto competition. 35903046 . 00
will do the work and theneuctum is out intended m offered to,ulc(See.7044.Business Re aired v5 ons
and Profession Cade:The Canuanmr's Liati Law do ret apply to an owner of q p.
propertywhobuildanrimproves thereon.md whams.etch wolthimselfor duvugh hen f�lq
ownemployees,provided provemimproid wit tienot intended moQemd the ween. /�®
ha
man employ=,
the building,prode improvement is sold within one year of Mampletien,the"vnen /�(/(�.o,'
build"will have the burden of proving that he did not build or improve for purpose of OCTsal.). i
❑1,as ower of the property,am exclusively contracting with licensed Mamnemrs to .5005
construct dee project(Sec.7044,Business and Profession Cade:)The Convectors LI- `
corse Law do not apply to an owner of property who builds or improves Beemon.and,
who contracts for such projects with a eonwctor(G liansed pursuant In the Centimes p
License Law. p(p'
❑Iamuemptunder Seo. .B&PCfmlhlsmmum 4 �
Owner Dam Q f
WORKERS COMPENSATION DECLARATION
1 hereby efflon under penalty of perjury one of the following declarations:
..and will mountain aCaNncareof Conant to self-Insum for Workers Cempen.
n,u provided for by Section 3700 of the labor Code.for the performance of the
wort for which this permit is issued.
have and will maintain Worgels Competition Wu Ince,u required by Section
OO Nae labor Code,for Ne peefermana of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
C...". � tvSNLC XE Pf1Pul0N iry No.:
CERTIFlFROM WORKERS' '
COMPENSATION INSURANCE
(ndsmNm raced not Imcampmmd if Um perh Is form hundred doll.(SIM)
m less)
I Certify that in the performance of the work for which this permit is issued,I shell not
employ any Promo in any manner an an in becomesubject to the Workers'Compensation
Laws of Califomh.Dem
Apt meet
NOTICE TO APPLICANT:If.after making this Cer intim of Exemption.you should
become suhje"in the Work"'s Compensation provision of Ne labor Cade,you most
,J Z. forthwith comply with such provisions or that peril shall M dcemed revoked,
0
ti CONSTRUCTION.isIConstruction
LENDING AGENCY
[—e l for whihthi thelUmrt lis consSo-Onnkeding agency for the perfurenec of
W 7 the wish for which thts peril ts luuctl(SIL.3097,Civ.C.)
0.Q Louden sees theme
n1. z Lenderl AOdrns
U O 1 Certify that I ban read this application and into the the show Information is
D.E COMM 1 agree to comply with all city and county ordinances and slate laws relating to
0 U^ building convection,and hereby authorise representatives of this city to enter upon the
tg] avow-mentioned property for inspection purpuras
Pry (War)agree m save.indemnify and kap harmlti the City of Cupertino against
y
liabilities,judgments,Mass,and caper which may in my my souse against said City
U In A PLICANT UNDEuenOf the RSTANDS ANDnanding of WILLWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REO}ILATIONg, 1•(66A
m Re-roofs
SI{narurc of App candGonRDam
HAZARDOUS MATERIALS DISCLOSURE - Type Of ROOF
WillPliantorforum Wilding omupantmommhaedlehuudonmamd
ri
u donned by
f25 32mY7Cupertino Municipal Code.Chapter 9.10.and Use Health and Safety
cave, El en zss3z(.)7 All roofs shall be inspected prior to any roofing material being installed.
El Yen [3 No
Wlll the applicant or future building aceupant um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
he]ardnus air contaminants u denecd by the Bay Area Air Quality Management all new materials for inspection.
im7
❑Yes ❑No
I have mW the Mentions materials requirements underChapmr 6.95 of the Califor.
7niaeal"SafetyCode,Sections 35505,25533 and 25534.1 understand thin if Um building
not curntly haw a semi thin it is my responsibility m notify Um occupant of Ne
ements whi uta be mel prior to issuance of a C"dflcam of Occup an Signature of Applicant Date
06,
Owner or mlllerl]eenl e1C All roof coverings to be Class"B"or better
v
CITY OF CUPERTINO � "g`
BUILDING DIVISION PE M1 '�11EZmTN 'C5�
BUILDING ADDRESS: SUM' S CONSTRUCTION PERMITND05020159
OWNER'S NAME: PEItAQi'�3Ue DATE
NE: SANTfARY 0 TROL Nil.
ARCHITBGT/ CINEER: BUILDINOPERMITINFO
BLDG ELECT PLUMB MECH
l�
0o LICENSED CONTRACIOWSDECLARATION Job Description .
I keen, M.that I sm licensed under pavedms of Chapter 9(mmmenunR
with Section 70110)ofDivlalon Sof Me Boob.and I'MI. ams Cotla,sed my Iicmm4
ufullfaaandeQen�J lJ/'firit5 ADD 660 ' (LIV. / 2 BATH/1 BED) &
Llcena Class�Ji�con
ran CSDECDECr REMODEL BATH, KTICHEN
ARCHITECTS LARATION
1 uMeraunJ my Puv shall be used v Public Hanna
u
Licensed Professional
OWNER-BURbER DECLARATION
I hereby,(Tian that 11. exempt from the GemlraelCar I:aemc Law fm the
O O following moan(Semon 70313, t,sircu and Pufmamu Cade:My City or county one
$ which im inu a pewit rc comft Wer,knprow,demml4h.M mPur any wucmm
Ny Prormiuinuantt.auomquimstheapplivntforwchpette" Bkatipetlwume^t ValUayt
thehe411m witpuntion7 O0)Pro visionsoftheanBoad m'andPoehew(Chodter9 Sq.Ft.Floor Area 000
$ (cat he is mg with Sections ma the
D Wal,
of al Bualnees up on,my i Cade)or
thatheis 31.5 b th y applicant
and the avis 11 the m Me eampumb Any Notation of
Section 7than five
my spd doll for a prmolt wb}eeu the applicant a a chit Penalty of APN Number - Occupancy Type
wt mote than Ow huedad dollen(f.50W.
❑1.vcam"ofMeproperty.mtoy employees with warps asMan mmmmpmusurm, 35903046 . 00
will m Me work,and Meswmura is not Wended oro0^md Or man(San.7061.Badness Required Inspections
eM enywh W Cade:The Cnnunoh Lhomeneand
Law don ar apply u rt owner of q ,
propertywM builds i ionIrcowsthemon,can subs doesetchwork-offered
his
Own employees,provided prowmimpuwntenuarcort VanoroQ.ed!m ale U,
however,the building Mor Impuwment is said did ant yea or borrowan,ateepose or
Wilda will law the harm of puling law be did nm Wild or Mprow fm purpose of
0 1, /
sal a t the
of project
proper(,sot eximm,and contracting CIN ravedmmanacmn a O/
wvtrwt the es am appl(Secy
as an 16,fluwwa of sed property
who Wilda
Code:)orler
ro Conuwmfs Li-
who Law dorsrotch ptyje%awnsofproper(vicesed pori Mprowa uamoa.and
,
who coni...(^Hoch Oukcu with•canuenorh)Iicenatl purwmlmtite ConuscmM1 /
Lxenm Law.
❑hem exempt undo Sec .B$PC fm thio woo
OwnerDau V
WORKERS COMPENSATION—DECLARATION
41 I hereby anion under penalty of perjury oee of the following decl^ knua
I haw and will mainuin a CeNhmte^(Conant m self-Iowa for Workers Compem
uuon,as provided for by Section 3700 of tea Labor Cade,for she perfotma^ee of the
work for which this permit Is Island.
kCerjbow and will maintain Workeh Compensation Insurance,as required by Section
IDOO of the laborCode,for the perormwa of Ne work fmwhina this Permit is houra
My Workers Campme mm Iowmen,ani.and Policy number am:
Cortico Iv,DR(f-C!M"'I Policy No.: ,
CERI7FlGTE0 EXEMmoNFlIOMWORKERS
COMPENSATION INSURANCE
(MLsseeuon nand not bcetmpleted lithe permit forawhmdmd della(Shan)
or leas.)
1 aNfy Not in Nc perfomanm of the work for which this Proton is human,l shall not
cmpleymy perm in my mm orw as to bemma subject to the Workers Compensation
Laws or CARIOMIL Date
Applicant
NOTICE TO APPLICANT:IL after making Mu Ccnificau of Exemption,you Wound
became forthwith
a the Wmkefa Compensation pmvisons of the Labor Code,You moa
Ofowith comply with such provisions or this Permit shall W doomed wwked.
y. CONST RUCTION LENDING AGENCY
1 bemby afOm Nat Mart is.construction lending agency,forNe Performance of
ti>
the work for which this penin a brad(Sm.3097,Civ.C.)
a Q
Lattices Name
ZLenders Address,
J C 1 ocr irY that I haw tad Nis appli d.and mean than the show Iufmmmm is
Fmrmm.l agree to comply with all city and cowry ordinenas and awe IoM raining no
U bolding construction.and hereby wthoree mpwnutiwa of this eirr 10 now upon Ma
r W mew-menuonad papery for Inspection purymeb
(We)agree m aw,Indemnify and kap ham4aa Ma City of Cup.tim against
i y liabilities,judgments,emu and expense,which may in any way Mora galnsr aid CRY
J4 in APPLICANT Nr UNDERence of MeRSfANDS ANding Of this D WILL COMPLY WITH ALL NON-POINT Issued by: Date
9
SOURCE R!7 ATIONS. p
(/I f/1 14(6601 Re-roofs
Signs=orl'Appplimuncontramr Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the sppliaat or lot.building aceupant port or hands haudow material
at deNrtl by me CupeNon Municipal Code.Chapter 9.17,and the Health and Safety
Com,section 255324)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes 0 N
LWill rhe applicant he future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hvAmm3 urcontaminants as maned by the Bay Amo Air Quality Ma^ascmcut all new materials for inspection.
District?
❑Yes ON.
1 haw most the hvwdom maanAis requirements underCMpur6.95 of Ma Celifor.
nil HCWhd:Safmycom,Somms 25505.25533and 25536.1 unmmund Most ifJa Wilding
docs not currently have a unsna that It Is my respovibllity to notify the occupant of Ne
requirements wbi tea be met prior 4 soyas or a CeniOcaanofocco Signature of Applicant Date
All roof coverings to be Class"B" or better
Owner or euthorw sent ate