01020049 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
219019 SAM FFPNQNDn QUE
OWNERS NAME. APPLICATION SUB DKr[
1311 012/12/21001
PHONE. SANITARY NO. - CON'IROLN(d
�00 ARCHI'I'1!CUENIINI!ER: HUILDl I'F.RMI'r INTO
NLUG EL1! PLUMB MRCH
Fz C7 I J —I 1'— n
as
L S m LICEleal I a CDK-ed undR'S DECLs or Ch.)N Job DCSCrlptl011
y O hemby amnesias sonIicmtadundo pnrvf.mes,iom,Cde9lconmmnense
-ms-w withsmforec and orlaivivinn lel the))money,and 1'ndbsvion,Qtle.:nW my license
•' cccw fos'cand clfca
o V Liccnw CLss Lfc.p
5 3 a h Dam Contractor
ARC lll'fECf'S I31!CLAIN'I'ION _ 1
a O S I understand any plan,,hall be heard as public reand,
w u o O Licensed Pove,sional
OWNER-HUILDUR DECLARATION
w=v, I bumby alfnn shat 1 mu excollo foss the Conmmmr',License Law for.he
F'7, Iulkswing maven.(Section 7031.5.Business and Pndissions Coxc:Any city or county
which myuim.a permit m cim.aruct,alter,ingnme,de.mhlish,or mpair ony stmcmm
m Prior dt lu isslance,xl.w myuims the nPplicam lin such per.inolilen,igned.na'sue
a.3- that hctalicenwdpunuannothcpmviumtsoftl Cnntract&,sLicen.w"w(Chawry Sy. Ft. Floor Area Valuation
(commencing with Srnion 7f Nn of Division 3 of the Ba,,iness and Pnffe,vin I,Code)
or that he is exnnpt Iherelrom and the basic for the alleged exemplinn.A,violflinn
of section 7031.5 by any applicant for it permit subjects the appfcam to a siva peoeM1y
,it not mate than live hundred do1m,,($500). A PN Number Occupancy Type
❑I.^s ovaw,of the oopery.nri^y. employ re,want wage.as mei r...le aompenmion. '
will do the work,and the hmemrc i,not intended or offered lin sole(See 7(w,
Rosiness and Pmm—on,Code:"f he Comme nr',License-Ww docs not apply to an Required Inspections
owner of popery Who hand,to improves thc.'con,laid who does such wad hon elf
or through his own aupluyce,.provided mat.such improvements art not intended or
offered Ibr vale.1),however,the building In improvement i,sold within one year of
est,mpiction,the raw cr-builder will have the banderol prov ing drat he did nun bhfld of
improve on,purryrse of sale.). Q�/
IP7,.,main,of the pmpent,for exclusively contracting with licensed contractors to /J C
mnmt the prop et(Sce.nA4.Basins,and Podes,i...I,Cssle:)The Cmr
omme ',
Laicense Law laws not apply to an co.net nl luopeny who(wild,or inmrave.s nhemun,
and who annracb for s, projects with a aomr:wwns�l�ensed for his m the
and
c I.icensc Ln w.
❑I am exempt under Sec. .H k P C for this rc
Owner/ `l� )ale �� 1
KbR'S CO, PIiRSAT10.{'DG LARATI(lN !/O
I hereby affirm under Penalty of he Jury one of the following declamtione /
❑ 1 h:me:mJ will nwintain a C'endkele of Course. to,661n,am lin Wnd.cr', -
n Compernanion, as provided 1^r by Section 3700 of the Iab r CWe, for the
perrnrnrancc of dm work Ibr which his Pc...it is issued.
❑1 have and will nmintain Worker's Compensation Inumnce.as required by Section
3100 of the LaMar Code,for she arl'nn nuns of the work lin which his peon:.is
bled,My Wbder s Compensation Insurance carrier and Policy number are:
Carrier. Policy Na.: -
CERTIFICATION OF EXEMFUON-FROM WORKERS'
COMPENSAHON INSURANCE '
(no section neral nnI he completed it permif is mr ane hundred dolmas
1A01B or less.)
I eenil'y Ibm In the pediannanca of.hes vend or which JJn pc oil i, uYl.I
shall not employ any pervo^in any manner so as In become.subject In the Worker:
Compmuunoo Laws of C;dhfo..a,Date
Applicant
N U ICED APPLICANT Under making this Cenificam of Exemption,you should
bem
eoe,abecl In the Worker,Cnmlwn,atlom
..pvi.lon of IM1e Loss...Code,you nn.M
CQ fonhwinh complywithsuch provisionorthis Non,shall bedecmN.,,kd.
z
CONSTRUC-HON LBNDING AGENCY
a ; I hemby affirm that there is a construction lending agency for the pert arable _
of the won Ibr which this PcnM is i„ucd(See.7097.Clv.C.)
Lender's Name
5 z Lc^der,Andres,
V O I eerily that I have read this appi eauun and stale that the above information is
CZ F correct I agree n,ca f,ly win 011 shy and county hrdinonce...... ,Inc laws relating
Q V
to building construction,and hereby amhaisc representatives of this city to cider uiwn
r thc:motioo,d prolwny torbwlmetinn Nrpo,es.
(We)agree m save.indemnify and keep homdev,the City of Cupcn'um againsl
(A liabilities,judgment,,esti,and expenu,which may in any way accrue agmrs,wid
V
City inconsequence ol.he g.'acting of this purnnii. /'�
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
REGULATIONSy'Issued by: P Date
SO' . fI ,
mg alnre pheamfComme,� Date Re-roofs
HALARDII MdingoIALSDISCLOSURE
Withy he Ca,pert m(muni Wal C,Ie.Cmm sdare9.12,had licthe HeaNtws nateety Type of Roof
as ddinel by he 320)1 no Municipal Calc,ChnPtcr 9.12,and me 11cuilh and Safety
Cads.Section 255)lfa):' '
❑ye, 0N All roofs shall be inspected prior to any roofing material being installed.,-
Alittheapplicant or future building necupeduse equipment ofdevices which If a roof is installed without first obtaining an inspection, I agree to remove
oral.hmardoos air emancoinn.s a,Jufnc l by the Ray Afa Air Gandhi,Management
i>i.Idelr all new materials for inspection. Applicant understands and will comply with
❑Ye.v 0N all non-point source regulations.
1 have read the b.olous nmmrials reyuimma s under Chapfcf 6.95 of the
Calilorniu I Ie:JIh is,Safcty Coale.Seen inns 25505,25573 and 25531 1 understand that _
if she building docs not cunenlly have a Iewm,than II is nay re......hllity m....Iffy she
oecuponl of the require items which must he met prior hr,issuance of'a Certificate of
()'cap ' I
r� 1^ t4 11 0' Signature of Applicant Date
11,`F Nils n or am mined agent �1 —7,-dj All roof coverings to be Class"B" or better
OFFICE