04120139 CITY OF CUPERTINO '^[ ' " '� �" °�"`'• � '
BUILDING DIVISION PERMIT CUNT' A.C'TQR., IN0T2MATIUN .
BUILDING ADDRESS: C BROOK CONSTRUCTION PERMIr"'04120139
OWNER'S NAME: PERMIT ISSUE DATE
JAMES
E; SANITARY NO. CONTROL NO.
(650) 965-8972
ARCHI'IEC"VENGINEER: BUILDING PERMIT INFO
BO EO PLUMB MECH
O
�OG LICENSED CONTRACTOR'S DECLARATION
I homey&(Rens that 1 am licensed under provisions of Chapter 9(commencing Job Description
^� with Sudan T0M))dDivialon 3 of Ne Business end WgWous Code.And lkwek
in fail fares aha a@a-•
LicevmClu. Lk., ELEVATOR INSTALLATION @ (E) PIT
3,-
Data
Contractor
A S DELLA AT1O
fluI understand my plans shalu l W used public near&
7understand
tl ii Licensed Professional
OWNER-BUILDER DECLARATION
0 4 1 kmhy.Diem that 1 1. exempt stun the Contractors :Anse taw far the
OO followinguiresa (Sudan 703L$e lot. ed Rofcuiunsh.or Any city uCounty
$ which requires a permit re quires the
alter narrow,h mulish.m repair ed m&nen
F- thanW.l issuance,pursuant to
lM applicant fm conausrmiuo0enm Law tlatemcm
(chapter Sq.F[. Floor Area Valuation
$ (cat he Is ing wast Suction700QanddeDi antfrnfNa Business and Pra(usy vi Code)or
Nat he a eumpt therefrom Autl Ne hula far due alleged esempdon.Any violation of
Section 7031.5 by any.pp0ant rte.permh Auejuu Ne.ppilunt to.civil penalty of 34kPN3tulrftr0'0 Occupancy Type
not mon Nen Bw hundred dollars($50H, u
❑l,as owner ofthe properly,m my employees with wages As duirsole compensation,
willda the work,and thestmcmre is notmmmdw ararteed mraale(Sec.Todd.Basra Re` uirebI s actions
and Profe cions Coda The Canuacmts License Law dues net apply m40 owner of ',.t,{ q Ute p
properly who buildsarimpmns thereon,sndwho doeasuh wmkhimsWor through his 9'Y
Own employ=.provided Nal Inch impmwmenu are notinunded oro@red far aka If.
however,the building or improvement is within aro year ofcempldon,the owner- ® ^ /Ute
builder will hew due burden of proving that he did Aur build or improve far purpose of //ul k( "DING untr llI®�
❑1,as owner of the properly,am exclusively cauuening with licensed contractors to
eanswct des Cut apply
TON.Business and rte who ns d,or
The Cmue0orl LI-
come taw does rot apply ed,owner orpropeny who sedd.or impo he Contras and
whonse Lace for each projeco with a comracmr(q Ilcenxtl pursuant m he ConuactoM1
License
❑Lem eaempl under Sec .Bk PCfor this mann
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 kraby AM.under penalty of perjury one of the following declarations: -
hew and will mu oaf.•Certificate oConsent to self-Insure fm Workals Campo.
anion,u provided fm by Section 5700 of the Mbar Co&,fm the performance of the
work for which this pump is issued.
❑1 have And will maintain Warker's Compemadon Insurvue,u required by Section
3700 of the Labor Code,far the performance or the woh forwhich Nis permit is Issued.
My WorteY Compensation hsAurarwx esrliar end Poliry numkr m:
Cartier �h/� Policy No.:
TI�FlLAt h Ut,EXEMPTION MOM WORKER:S
COMPENSATION INSURANCE
(Thu section need not kcomputed If the permit Is foram hundred dollars(Slip)
or lest)
I certify Net In the performance of the work fm which this permit is Wood,I still not
employ any person in any mannerm As to become subject o the Workem Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making Na Certificate of Exemption,you should
bacome subject to the Worker's Compcesedon provision of the labra Code,you most
OO forthwith comply with such provision or Nis Permit 0011 k deemed raveled.
„Z,i
CONSTRUCTION LENDING AGENCY
=
[-+ IknbyeEbmN emosi...amr tion lending agency far Nc performances of
the
fY,� work for which Nle permit Is taswe,.
d 3Vv.C.) '
Izl Q Lade, Name
z Lender'sAdd=
U O 1 certify that I Mw read Nis ppl tion mM sou Nn du slew tar omua.u
COMM 1 agree to comply with all city and county ordinances ad mu Is"mladng to
O building construction,and hereby Authorise represcanadvol of this city to enter upon the
fA above-national propene for Inspadanionppurposes.
Ly,LL (Wc)Agree tosaw,indexpenand tech harmlw the Lily.(Cupertinoq.im /!
„y Z inconserenceojudimcmM.theeasuand ex this aswhich May in Any way serve ayalnn said Cky
V z A PLIANT of UNDERSTANDS
SA permit -Jl
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date - l/
SOURCE REGULATIONS.
Re-roofs
Signuurt of AppliesDData
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WH]bac Applicant ter fuuni buildinge,Chaunstowor anduhu.Noumaterial
As deRmd io rix Cupertino Municipal Code,Cbeptor 9.13.and the Health and Safety
Code.Section 35372(4)? All roofs shall be inspected prior to any roofing material being installed.
You
Will the Applicant or(atom building aacupent sato equipment or alert=which If a roof is installed without firs[obtaining an inspection,I agree to remove
t neurdau aircomemimna u ddn d by the Bay Am.Air Quality MAuagemcm all new materials f • Spec Ion.
lards, �I
❑Yue J[]Du
Ihewmad Nehe,Sccgomate5.2533 wed n534,luChapters.hulfUlc Wilding , '�L�L
or-
nice Hcadl.,IL]yCede,&cdo 5 iL 3my=po3 bili,y nticrsudthatlflhckOld,
d= emrantiy h.w nu4 uitamy map. bilhymndl'y Ne aceupAul of Ne
emu wn46 ,ak ' dartoic. .ccmec.te or Occa azure of Applica ate
43 1 onmham Date All roof .ratings to be Class "B"or better