00070100 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
bH!l i-H PAULA AV BUILDING A 1K_.. PERMITNo,
00070100
000
DWNCR'$NNN APPLIcAns. SU t I W.
PHONE.. SANITARY NO. CONTROL NO.
FOCARCHrrECUENGINEEH: BUILDING PERh11'r(NPU
m❑ BLDG iLECI' PLU?Ila glECll
i U IJ I_ ILJ -1
��62
u v Loo th,[a CONTRACTOR'S DECLARATION r
�� IherehyafEnnlhatlamlicenuJunder prnriviansofChapmr9(commencing 7El}1R ELECT Job Description
° weir section pn(wl ornivi.inn3onne nbntess and rmfes,mn<c,de,ane arty Rance
is in lull force and rE,,r
z w a I.ianse Cl... Lie.a
u Dare Cnmranor
raS 3 u.v ARCHITECT'S DECLARAIION
C t=o,5 1 umcnuand my plane shall he uwJ ns Public rccnms -
Licensed I'mlawi,aid
�zr<
°m'S el P4 OWNHR-BUIWER DECLARATION
^-v 1 hereby arfn,n that I am exempt r,o,n he comraemt.Liansa Law for he
t-g a Rlunwmg mason(Scai:oat 0313.Rnmc.s and PBA..on,node:Any city or Botany .
F C which mi,nne,a noil lis ebb o,cl.Idler,ilnprnva,Acmulislt illi I'cpuir anY etn¢'lurc
i Cam
prior ill su
its ieance,ulso requires the aplilicanl forsuch ptnnluilile'n signeA sfinemem
,ha,he is licensed Portman,In the inowniwtn ofine Commemrs Lieenw,Law(Chapter 9 Sq. Ft. Floor Area Valuatio
(commencing with Section T)00)of Division 3 of the Hus mels and Poi C d,,)
rz Ilial he is caanpl fherdinto and tM halls for the alleged exemp,inn.Any violation
od Seation nnls by any uppdeam ora Parma seh,lau he applicant d,a cisil Panmty'
of,lmtomremanfive handmedollars WWI.
_ A ). 3-J• Occupancy Type
❑1,as owner onhe props"o,my employees wire wage.n weir sale cmrpcmadon.
will do[tic work,and the structure is nit intended or offeree for sale(See.](W, FE
Invi'n,".,it flnfxw.i...xs Colic: e Commm, m103 — U
a 's LLable Law does not apply
an Required Inspections
ow,wTof prop,"Whonmed.m,im,owe.lh, .
oaaha
cal who .such work h'Imseu' 304 — ROUGH ELECTRICAL
or through his own empo,ol provided that such improvement%are nit intended or
offered for m1e.If,however,the building or impmwment is xdd within one year of
nnpletion,be owner-builder will nava the burden of proving that he did nol holder -
itnpmvr for puquse mf salad. - -
casmor of the p,openy,am exclusively contracting with licensed connodon to
construct the pm7act(Sec.7W4.Business and Pmfes.ions Code:)The Contmemr's
Lice se Law fin not apply to an owner or property who build%or improves therein.
and who la'stmll pmjecb with a enntntetegx) hcenmJ pnrsuunl to the
ors License Lax'.
0 1 am I am exempt under Sec. .B R P C for this reason /
—
er ;1' I,NSPITON'DIzC1.ARAI'ION /9
mI hereby aRmi nndcxrnaOpc Jury one of,hc following Jedurvtions: //
:] I have m unJ will intaia ulicme of Conmm to ndf-ibntn for WorAois v 7\
l_oanpeno ;at. I. .....lido, tar by Section 37W of the Labor Code. for Ina
perbrmance of fire work for which this pernilt Is issued.
❑1 have and will maintain Worker's Compensation Inmmnce,as required by Section
37W of the Labor Calla,for the peromeanee of the work for which this Permit i.
.lard.My Win an s.Cbinpen...It Innumnce carrier and Policy aundi r are:
Came, Policy No.:
CERTIFICAI ION OF E%EMITION FROM WORKERS' '
COMPINSA'OON INSURANCE '
(This uc,ion need nal he completed if the permit is for line hundred dollars
ISI W I or leu.)
I«nify that in the bafomarnce of(M1e work for which this permit is issued.1
chill not cinnov any Pena In any manner sr u.urhacruna 90ijttl n the Worker:
Contpen onion Luws of C.hkaoia.Dam
Applicant -
NOf10ETOAPPLICANT.If.ane,makingthis Ce%fifi dor rsempdon,you xhumid
Income subject m,he Workeh Cnmpcns non provisions or the Lobo'Calle,you runt
"m
1lnlhwlth aongdy with pact,Prov........or(his perntil.hall he dcmoed revoked.
FCONSTR=ON LENDING AGENCY
C > 1 hereby all that them is a eomruaion lending agency for the performance
W nl'Ihe wok lin which this PCnnir is iou,1(Site 31191,Civ.C.)
Qhander's NE ,
7 Z LcnJcr's Address
U l canny that l have mad this application and late that the araove information is
Lz E.a
correct.1 agree n,comply with all cityand county onlinaneb and state laws relating
Q V to maddinget,,lamtoa,and hcrcbyamhnrim repiewatatives off his city to eater upon
toe slave-mentioned pmPerty m,inpeeunn PmPi.es.
(W'e)zgreems am.Indemnify and keep harmless.the City of Cuperino against
'n liabilities,judgmenu,coxa%and expenses which may in any way accrue against.aid
V Z City in em otapinsn of the granting n1'thls perntil.
^ APPLICANTUNDERS'I'ANDS AND WILL COMPLY WITH ALL NON�IlOINT ISRUCd by: Date •7^,•F
'�
'GULATIfINS.
amnfnpprcanv ,ntmuor Date Re-roofs
f"A,AR w" MAfER1AL$DISCLOSURE wi111ha a:ppuea:aal orbit, Iff klatgiceltpalt t store or hampe ha..ardous nwedal 'type of Roof
us Aetinld by the C.p oat.,Municipal C,de.Chapter 9.12,cad the Heahh and Safe', ,
Code.Section 25532(a)'1
❑Yes ❑Nn All roofs shall be inspected prior to any rooting material being installed.
Will mu atprcaat or rnfole building ocenpottl uscegaiPtoentordeviaswhien If a roof is installed without first obtaining an inspection, I agree to remove
hballou,an contanJncon,us defined by fire lin,Arca Air Quality Managene,rd
namct^ all new materials for inspection. Applicant understands and will comply with
❑Yes 0 N all non-point source regulations.
1 hove read the hba chop mumrlals requirements Imdcr Chapmr 6.9.5 if the
California IIenIIh&Sudety Code.Scclion.Ls5os.255JJ nnJ 255.iY.I understand the,
ifthe buildingdoes not currently have a tenant.that it is my resgmsibiln,lomairy the '
occupant of the requimmenti which must he:net prior m issuance of a Cenificote of
s y' Signature of Applicant Date
r rirantnotiaee, eat crus All roof coverings to be Class"B" or better