01020034 CITY OF CUPERTINO
BUILDING urvtstON PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRrs1:0Ec7 N. STELLIN RD HZU FERMI'TNO.
010200..,?
4
OWNER'S INAML: HZU APPLICA'nON SUB PATH
02/07/2001
ONE - SANITARY NO. COMfROL NO.
BUIL G PERMIT INFO
q o ANCIIITfI'I'/IiNGINF:r:R: HLIf`G PLUM1II—IR MECH
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�aC I_I L i
ON LICENSEDCONTRAMOR'SDECLARATION Job Description
y ° hereby a(Enn shat 1 un,Iiea,.wd under pmvisians of Chapter 9 U ufficneing
r4taa w .Scatlan7tNMn anrd.ahn 3in
m'pne Huaes P
nnJ /rn,r".in/n.�enne.nml my l'een,.n TEMPPOWER
_m2 nfulllorce anJellecl.
s w Liccnx Clus. Liv.
°a t' tc /7� Comate A
'sat a —y(-C �rllcurl'hcrs.rhzn nT10N
t'—`° I anaurvand toy plan,.nml�Itwd.n pumie record,
p`s Licensee 14 it
[e OWNER-131111DER DECLARATION
I hereby affirm than I are cscu.pl from.he Cuntruchn,l,iwnce Low for the
t Z i fallowing reasnh.sectio 17031.5•Badness and 1'mfcssiuna Cola Any city or county
E=M which nitrate,.perraitaol. he,intrusive.dcroAM,I,,repairany w rote
pJ
Inior to itsy the applicant fsuch W t It,lle geJttmem
o,a
[,;,I liveawdprawrin(,),he provisions(sflhc Contractor's Licers,r (Chapter 9 Sq. Ft. Floor Area Valuation
Inn mulywth Savl 91HNn ,t DM,a , 1'd ❑ ,' dl 1tsm ,C,lo $0
or that he in eacmpt.hcrcfm a and the basis ler the alleece csennp uhr.Any viola n n
o(Seclinn 71111.5 by,tiny applicant for a peruit eobject,the applicanl to a civil penalty
of mom than five hundred dollars(55(101. APN Number Occupancy Type
El 1.as owner of n,.or locos with wa•es an their sole umn tion. 32Ea08051. 00
irons > any s g pensa
will ne the work.and the ode The
i,not imendcJ en a Low for sale(Seeapply
7,,an
Resines,and profession,hb Code:The Coal ovas tcutr's uennx it d d«,bat ork hian an Reqqaired Inspections
nrv@nnrprapartr was mama l mire ate such and whit cants,are wok ndad or 103 — UFER
mgh bis own boveve cc.provided That such impnwcnmold um w.ihmn,lcd or
.
ondredlo sthe.wner-builderhe holding
vethe rrdenof proving N;min nue year lir 304 — ROUGH ELECTRICAL
u'rive bar thepose owner-builder will have the burden o(pmving tM1a he did not buil)or
.npra.e rat paupua•
❑1,as owner rel the prhpcny,ran exclusively contracting with Iacused coinraclu s Io
eanswet the project(ties.1614.Business and Prufeuiuns Gtde:)The Cuntracmr'n
License Law docs not apply to an Its her of prupcny who builds or innproves thereon.
wM1
anA o eort, ler such pn!jec...wish a sonvacununun
lsl licensed pm m the
I I'v
cut h o.' hrttse Law.
❑l ane es,ht,u under Sec. - ,R&PC lin this n.no
Owner Data /3/
WONKRR'S COMI'IiNSA'rION DEChARKfION ,^
I hereby aff nn under penally of perjury one of the lidlowing dcel.mhiom: /
I have and will maintain a Certificate al'Consent e, self-insure for Worker's
napensnion, as pmvfirst lin by Scolio.. 3700 of the Luber Code. I'or the
,ifonhmrec orthc w for which this Penni.is issued
❑1 have and will maintain Worker\Compensation Insurance,as required by Section
31110 of she Lu1mr Care.for the per orrience of the work for which this fennel is
W.My Worker,Cn..B c.anion Insarunce Barri ,i I Polley nwnher arc:
C._, Policy No.:
CERTIFICA'T'ION OP EXEMFI ION FROM WORKERS'
COMPENSATION INSURANCE
rrrs section need not be compleled if the Pennil is far he hundred dollars
(SIM)ter Icu.)
1 ecitil'y that in the peri a'mnace of he wod for which this permit is issued,I
shall mit cnnplar any Iwason In any insurer so;is to become subject to the workers.'
Compensation Lards of California.rate
Applicant
NOTICE 10 APPLICANT:B,after making this Cenifica a lir L.emption.you should
hectare subject to the Workers Comic"aline a-vi.luns of.he Labor Cade,yon mast
2 forthwith cdmply with such provisions or this Penni.sball he deemed revoked.
F ^ CONSTRUCTION LENDING AGI:NCY
I hereby allinu ohm there is a comnua.lnn lending ugvncy bre the perrannar-
aI [,a work far which this pcnnit is Iswrsl(See.71191.Cie C.)
0. Q Lender:Name
z Lender's Address
V 0 I ccrfly that l hive reed.hiss eppl kation anA"tam due the above lnlbnnution 11
(r. F. coned.I agree at cn.nPly with ,If city and county ordinances and omit lawn evicting
Q f.7 to building construction.and herchv uniforms,representatives of this city u,enter upon
the aMocorcutioned property forinspection purpoe
ss.
F y (We)agree h,ave,indarnify and keep harmless the City of Cupertino against
liabilities.judgment..casts and cap:n.ws which any in any way accrue against said
V z ty in cmnequence(1, he gfaming of this Froomy+�'
AYPLICAMS �wILLCOMPLY WITH L �/ Issued b Date
SOURC. T S y'
I o Ap. aahCantms lir cmc Re
-roofs
HAZARDOUS MATERIALS DISCLOSURE
will the applicant or furore building tcf bar,sere lir hmalle haazNu r,mmanal Type of R
o litho by the Cul,coibn Mnnicip:d Cult Chapter 9.12,and the Health and Safety
Curb,Sootinn 25532(x)?
EI Yc9 0No - All ro s shall be inspected prior to any rooting material being installed.
Wil Ithe applicant lir future building occopent use c,hipnnnl or devices wbicb If a roof is installed without first obtaining an inspection, I agree to remove
nth (lots tar cnnmhournI s as dcfinnl by the Buy Area Air Quality bfana'aawat
Awri n all new materials for inspection. Applicant understands and will comply with
❑Yes 0N all non-point source regulations.
1 hoe read.he hazardous materials requirements under Chapter 6.95 of the
C'nbrnia llcolth&Safety Code,fivoions 25511.9,25533 and 25531.I nndedmnd.hat
if c building docs no.currcn.ly have a tcnan6thm'h is my responsibility to frody the
rupvm lir ma rcyuircments wmen bout R and prior ret i.....ce of o Cenificam of
yce.'a"`y' d� > Signature of Applicant Date
—.1 -1- ���� All roof coverings to be Class "Br' or better
Owner or timhoria gem Dae
OFFICE