01020119 CITY OF CUPE RTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS' PilRbirr NO.
1 li z�
OWNER'S NA APPLICA'T'ION SUB DATL
TA So WA/Y
PHOis MOSANITARY NO. C'ON'I got.NO.
6
❑z>, ARCHIrECUENGINEER: - BUILDING rEHMI'1'INFO
O ULDG lPLUMB MIiCH
W
Gni I.I I-1 IJ IJ
LICENSED COMIKAanR's DECLARATION Job Description
0 5 h c 1 harchy alrrnr hm 1 air,haloed ander pmvixion.(11 ole ter)aommeemmng
pw" w with far
card after sinn3oflhc ltusincs and Pru&..ions Qdv.and mylittmx
¢ '�]yy in full fnrtc and nrrA a�/N 5 8 /i
Cii:'W Q Lianx claw !� Llc,pa. Data _ J ri 7s"' TEMP POWER
��`C I unJemmaJ my plans shall he u,aJ u..PuNie raconls /
i a p O
Licensed Mofeaianal V/
x OW NIR BUILDER an
contractor's
ur w 1 herby.(lien on 11. cBusin form me Colton o License Law for me
Whirs ea,reason.(Salam 7114 am.flit Business and Pmree,iom Code: p r city o ammy 0,
ca x 0 wit cit 1 . 0 ret f , t filter. I It yisn r' r wmdure
i 3� palet f '0o"Hire,pr pions: e l I m mid l is g Samna l
- Int.. ci wdpnnamet m provisions nil il t easel License Los'(in,Cad9 Sy. FL Floor Area Valuation
ammr,m is r cairn,haref 7(X01 t le,hasion i a(the B,ad a and P..i cAnurns lan I
or Sect nu is 31.3 b areretrmn and Ise bash Gov the subjects
the eacmpli non.Any l Penalty
of Solon a Il LS hY any handled
am lar.(¢men subjats ehc applicant ee a eland anally
or nal rmarc man eve nandreJ.learn(asnB). APN Number Occupancy Type
❑h m owner of(he property,or all cmphwas,with wages us their ole compensation.
Will du rile work,:red the s(metur,is nm intended nr offered for tale(See.7114,
Bm testand rrrrfce .La e Law doe as apply to an Required Inspections
Lilorte Cede:dam Coaradn'oad
mine,
of his ow em loyees or improvesat such improvements
hrdoes
are such work nixed or or through his own employees.s, moidcd Gila(such impmvcmcnts xm ern ice, c;f or
oliceill ,thea 11,arweilde, inemai, hebunpn of or,n.oda he did ane yild or 304 - ROUGH ELECTRICAL.
npplmnra.the
urpose r.nmBJer will nave m,sante..f pm.ieeg mm h,aid nm Haan o, 501 - FINAL ELECTRICAL ENERGY
i�nnmv,ser prtn,oaa lead..).
❑I.a,owner of property.am exclusively cosseting win licensed romraemr.m 505 - FINAL ELECTRICAL
m.aruct the pe ject(Sec.70114.Ifnsinesv and Profession,C de:)'Me contractor's
Lies ,c Law dee am apply to nn I-mr n1 pmperty wha hulld,or inrpro,s thereon.
and who connotes for such prarjcces with u cnntmarn(sl licensed personal to the
Conamstufs License law.
711:un exempt under Sec. ,B&1'C for this reason
Owner Dam
WORKER'S CIIMPENSAT(ON DECLARATION
I hereby mlirm under mally or perjury one of he following Jeclaratien.s:
❑ I leave and will :adinaLin u'Cenili ale of Consent m selGlnsme for Wudd's
Cumpcnnion, as .....tried for by Section 3700 of the Lhnr Cole. for the
perhmmtnee of the work for which this pemat is issued.
❑1 have and will maintain Woder's Cnmperuation Insurance,as squired by Seninn
370 of he Labrm Cada,for the performance of the work for which This permil is
kae,d.My
Workcr'x r ewe .....rano,currier i I Tenney namncr are:
Carti _ I / Gorey N.
CEHI119 . 11(N Oh EKEMPI ION FROM WORKIeRS
COMPENSATION INSURANCE
lylils section need not he completer(If the penult is for one hundred dollars
(41(X))or Ica.,.)
I certify that in the x,fornunce of In,work for which fills Irermil is i..ucd I -
Ooll nod employ any p<•son in any man Is,so us ,,halt a subject m the Worker'
Compensation law's of California.Dam -
Applicvm
NO'HCE TO AI'PI.IcAN'1'.IL alo...raking mix Ccnlficma rte Eseneptian,You,hould'
became amen m the W..or"Compensation pnwlsion a of the Iabor Coda you nom
'Q O ennhwim comply with wch provision or his permit shalt be deemed revoked.
F7 CONs'rRUCrION LENDING AGPNCY ,
7I hereby affirm that there is a complaints lending agency for the perfnrmamc
aI the won for which this pen n,Is issued(Seo.Nal Co.C.)
Lender's Name
C 7 Lenddv Address
V Q 1 nrily that I have real in,application and slate mut the Aswe ialbrnmfion is
ks F. carred.I:rgme m comply wllb all city and county mth..nccs ani one laws miming
Q V Io hurcing"mennefmn,arca hereby rum ice m,m,artaavc,offlix city to an,....pml
he.hervomcntioncrl pmpeny for in.spomiun purlarses.
ti y (Wc)ugacto save,imimnnify,and keep hnrmles,the City of Cupertino against
V1 Irdalirios,iudgn eno,costs:red cwc,c whit any way uccrnc eguin.a said
U % city in con.eyurmce or d grant.• miv,m I. �— �f //)l
APPLICA WILL COITN AI POINT Issued b Date �f� - (/
AND
SOUR EG(' r HSS y'
1
sign.inmor,ppm uin ...15FY
Data Re-roofsSURE
Will tile npphcamatmmrclndldlngIKcalanlstore ornammelia-die,.renal Type ofRoof
as defied by the Cupertino Municipal Cole.Ch.pmr 9.12,uad he realm and Safety .
CWc.Section 25532(ul'1
13 Yes ElNo All roofs shall be inspected prior to any roofing material being installed.
Will the applicant orfuture building oagpamtuse equipment ordevices which If a roof is installed without first obtaining an inspection, I agree to remove
fir h:v:vdoas sir ama,minant,as AdinoA by He Ila,Arca Air Quinsy Munapemvm
District;! all new materials for inspection. Applicant understands and will comply with
❑Yes 0 N all non-point Source regulations.
1 have rcnA the Immrdous macriulx reyulrc b under Chapter 0195 0l'the
California 11.1h k SIM,Code.Sections 235 35.3 J 25534.1 undcrload mat
i1'Ihe holding docs nm aurrcnS' .mcatanu .mafitsm respur'hilifyforrayhc
n pun f tilt re one ALich muM hC reef m n ,u nitiaum If
""' " g c 3077, Signature of Applicant Date
owner or anrhad,edagent — Ume 'All rool'coverings to be Class "B" or better
OFFICE