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BUILDING DIIVIISIONNOPERMIT
NFCONTRACTOR INFORMATION:
BUILDING ADDRESS:
PERMIT NO.
OWNER'S NAME:
APPLICATION SUB DATE
'-Tll
'ONE:
SANITARY NO. CONTROL NO.
ARCHITEC (ENGINEER: a
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICSNTRACnder p Dis RATIN
Job Description
I herchy affirmFilhatED�cOficersed ons of ChONer 9 (commencing
nn3 of the Businessnnd Profcssiunx Cade. anJ my license
is with Smtimearoa1 effect.
to full force noel effect.
DEMO FINALE®
License Class Lic. M
Data
Lr
ARCHITECT'SSDECLARATION
be
NOV 0 tg '[ 2002
us public
1 undcmmn0 my plans sM1all .,oil as
C C
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby (Stas on 1 ore exempt from the Conoas Law for she
BUILDING
Co e: Any
Polishing uiossa , 7033.5. Business and Professions Cade: Any city or county
permit to aline improve, demolish, or repair any
which requires a permit rnres
re the
statement prior to its issuance. also myuirt.uhcnpplicom hn such permit to file asigrrN stamrr¢nt
S Ft.FloorArea
F f �p q }, I(11 . � is j ..
• Valuation
[last he it d-ZI! purmunind to the pro s of da, Contractor's LicenseLa (Chaprer9
Sen 7") fD' 3 of the Business dP fo Code)
(commencingwth en us
or Net he is exempt thetefrons aniline boss fur the .tlleged ese npnim Any 1whr nn
11 .1 ..
3 ] CJ 12 Q 0 1 . O
-of Smtisn 703 LS by any applicant for a pemtit subjm, the applicant sa a civil penal..
of no mart than five hundred dollars x500),
APN Number
Ilr..1 " Occupancy Type
°I. as owner of the property. ormyemployees with wages asthat sole conpensuthm,
NO ASSIGNED INSPECT
ONS
will do she work, -and the svunure is not intended or offered forsake seo. 70114.
Business and Piolcsslons Code: I'he Contractor's Licenu Law does not apply to an
Required Inspections ' ''' '' •"`
owner of property Whit wilds or improves thermn, and who does such work himself
that such improvements ort not intended or
or through his own anploer,
--affnee for side: If. nnwever, me ntelain. __. -t it tdlewithin one ear or
th building a
bob rsof en
- .____. ...._ _. ... ___._..... _____.. .. ...._ _.. ... .._ _._. _.. _._ ....... _..
1 i the owner.wilder will have the that he and nota sed or
c ion, proving
iamp
mprove for mrmnse of sale.).
p(Speny. am «da mronWg him rantT ens m
'': r '..;',: v.:,;T ,. 'u
BusinessContractor's
constrict project (Sec. 7(oLr, Business and Professions Gdc)The ConOaaor's
conswa thedoes
I'r.' ,
Licenu Luo tact nm apply mon owner of property who builds improves
'
se i in th,
who contrast for ,such Protects with.o.cooinnorlsLlicenud punuam to Ne
.....__.._.. _. _..._._.___.__.. ...._.... .. _.._... _..._... _..... .....__ .. .....:_ ...._........ ._._....__.__.. __...... __. _....
C mnvmr License Luw
C
°ol am enc rpt under PCforinisaeson
pare o 2�LAKATJON
:R'S CONPEN I ' D
I herchy uRnm undtt penalty of pepury Dile of the follawin6 dedamtianr
J I have andwill maintain a Cenllicatit of Consent to'self-inmre for Worker i
Compensation, as provided for by Section 3700 of the Labor Coca, for the
perrortmtnce of the work far which thi :permit is Issued t
° 1 have and will maintain Worker's Cbmpeneaiimi liisutancc, as required by Section
3700 ofthe Labor Code: for the perfoniunce'of rho wvk'foFwhich his permit is
nulled: My Worker's Comp:noth. Inarhnce carrier bnd Pdicy number ore:
Cance
Is4s s t t if
„` CERTIFICATION OF EXEMPTION FROM WORKERS';",
IN L[•,I,i
-
�COMPCNSATION INSURANCE
__
.
• I (Thrs ueuon need not be completed if the permit is for ane hundred dollars
, s
p$L00) or h ss.)
I cvamf, that in Ise pefformadefth k f which t pe t ucd, 1
-
-----------
'• '/['s i. ry
ihill nos nY,�'' rW are,1 bl Workers',Is'Q
,ply
Cm t Lnws f I lOa iVthor
p cam
TO APPLI t ihl CnTct tE mpto you should
CEsublmt
't
ante io the Worker s C spenso a pro ss ons of the Labor Code. you most
fonhdith comply with such provisions or this permit shall be dimmed revoked.
CONSTRUCTION LENDING AGENCY
t FI'°"'si1!'61..'i !•.'
I hcieby affirm that there is a construction lending agency for the perfominnec
... F" .' .•. ,
of the work for which this t is issued (So,. 3(197,,
Ie^°i Civ. C.),
L<nder's Name ,,, , ,, ,,, ,, •;.,-__
_ ... _.. -,., , . , _„ _ __, _
Ada ,x - .,
L'D l .•.. , .1 / /�
—
11,ilan
I nee mat I h c a tn'. an u n and .tate Nat the above information is
t/Cl
city
1 agree to comply with all my end county ordinances and state laws relating
touea
hereby auth repusentutives of this city to enter upon
tobuilding consoned
pr,and
ion
the aboses
ve-mentioned propenyfor ins ,
fy%'dikepuryoriess aini inu
I Wq agree to save, inad and keep harmless the Cary or
cone
x.. which may in any any eccmc ageirut said
linbilitics, jsdgmcros, costs std against
/rz,
m.g f,hi
City in cons'quenc of'no gmming fihis permit: ,"
APPLICATTC IRSTANDSA' WILLtOMpLYWITHALLFarN INT I
-tEGU 'IONS. �1I
I//
ssuedb Date
ya
SUUNC .
RQ -LOOTS
Si at a ApP otnra t !/— t
„!''-
HALkR S MATERIALS DISCLOSURE
booth appgm torr 'b lding oictricurn ,am or handle haeordsu, culmil
Type of Roof :---• _
as der cd by. the Cupertino M c p 1 Code Chapter 9 12, and the Health and Safety
i,
Coda Suy.,1'!12(a) -
r
_ '. a:4.'f,,t.f ,117;'•.••• i
°Y03"' ' ' t °`°;"
_. All roofs shall be inspected prior.to,any roofing.material being -installed. -------
P iWill the pplY t rr t buildingoccupant_.eequipment devices which
If a roof is installedWithout first obtaining an'inspectioldsl Agiee.toli'emove
iih Vous car containment as refined by the Bay Area Q ldy Managemcni
ist t " 1
,
all new materials for inspection. Applicant understands, and will ,comply _wlth_
°Vrs —., , :. .- , r
all non -point source regulations...,
I ha a iced the hovaNnus maiedals mil.immems under Chapter 6.95 of the
Calih�rrii. Health& Safety Code! Sections 2550535533 and 23534..1 understand that
fOr, w Id'gdoes t currently have. tananl In.' it y.ep blayto nnifythc'
occap t f 'he r - s. 'h'c dxt be met pct to'is m<e of o C ni case o
Om,pancY
a � 0 �/ j
Signature of Applicant Date
All roof coverings to be Class '13 or better
Ow unturned agent . • Date
r
11
OFFICE'
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