01015058OFFICE
CITYor currRINo
U n S
BUILDING
CONTRACTOR INFORMATION:
PERMIT
BUILDING ADDRESS:
19 6 -regfv Ave
Al/AN £�EC;Z^121
1-17RMI'I NO.
OWNER'S NAME:
APPLICATION SUB DATE
SA GO WITZ-
P.13.60K 1743
PIIUNn.
SANITARY NO. CONTROL NO.
�} o$ 3 R s— 14 01
G BELL. C-4—
P re 0
ARCIUTEC OHNGINEER:
BUILDING PHRNH r 11,11:0Fu00
13LIK PLUMB M[CII
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I-1 - CI toil
N 2
S
LICENSED CON'II O
RACR'S DECLARATION
Job Description
v'.
1 hereby union that I ant Tema under pmvlsinn.v of Chapter 4 (commencing
L,y Fs
wim nV(akll of DivisionlnOhe Nasines and l'rofessiom Ctdc. and mylicenu
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In toll fnmu and alfccl.
tollI
I.icr,o Cbss _ G -10 Lic, #.-65'0-3-9-0
0. 6 V
DOIe Jif Contraetm- 4. e
Y�
ARCHITEC)"S DECLARrMRSQ-
I undcmm�J my glom shall h uxA us public raahNs
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P_\ r I OF—V
V\11�V
w O O
Pone
Licensed nfsionul
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OWNER-BUILDER DECLARdIION
rum Lice.¢ Law for
1 beach, am. that 1 am emmpl the Contra'mr's IM
following teawm. (Section 7031.5, Business and Professions Cole: Any city or county
'
wmvh y p n t t t It p J 1':1 p y %uunurc
.5a
prod I 1st 1 m pll' tl It file 6 J.rmtunt
Sq. Ft. Floor Area
Valuation
that he is li,c dptir,tbann , p )I the C ancon, License Law ILhap1e9
be,mmencnng with Sectionligh)of Division 3 or the Bo.ate.s and Vrofievoinns Cede)
or that he is exempt therefrom and the Favi% for the alleged exemption. Any violation
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
APN Number
Occupancy Type
rant, non, that fee hnmdred dnllam 0500)
❑ I, as owner of the property. or my employees with wages as their sets, compensation.
Required Inspections
will do the work, and the structure is not intended or offered for sale (See. VOID,
Business and Professions Cade: The Contric nrs License Law does not apply to an
r of property Who build. or Improvthereon. and who docs such work himelf
vImprove thereon.
-
or hie own employees. avoided that such improvements ire not Intended or
/
vcvee building or improvement is sold within one year of
nBered for sole. If, hmr, th
AV
completion, me assma-builder will have the human of proving that he did nm Wild or
ID 1. the poo inI.-Ivvly t t ywlth l's, J tnwmrx1.
construct d project (See 71W BO%iFICvh and Profico,ion, C d ) I he C tow"Wi,
lace". W J t apply t ndp perry who Wi1J t P thereon.
and who cmlmoa. for such pami with a contmemars) licensed pursuant to the
0/
Cnnnuvum.v Leon, law.
❑ I ;an cac a,, under Sec. , If & 1' C for
Owner Dam
WORKHR'S COMPENSATION DECLARATION
I hcmby of nt, under permil} of Pcr)'ury n ns, nflha Iullowln, dccla own,
- E3 I have and will maintain a Cenifcme of Cacao w self-insure, for Worker v
Compensation, as provided for by Senion 3700 of the Labor Ctde, for the
performance of the work lira which thio permil is issued. ,
❑ 1 have and will nuimain Worker's Coinixosation insurance, us rcynired by Section
31110 of the tabu Cole, for the performance of the work for which this permit is
sued. Nfy W'orker's Compensation Insurance carrier and Policy number art:
Currier: 110hay No
CERTIFICATION OF rXI M1'TION FROM WORKERS'
COMPENSAI[ON INSURANCE
(This section bed not he completed if the ii is for one hundred dollars
($100)nr 1...)
-
I vend, that in the performance of the work for which this permit is issued. 1
.hall not employ any penin in any manner on as to Femme subject to the Workers
11
C.onlpenwtion ol ACullttnim. D
nppliuhm /.l.-
.
ANTI lie .should
ANI Il.o .k tg moot Eeennpliood,
Nt...toc
,
Wernne subject m the Worker's Colons or this provisionsof the IaWr Cede, ren mast
lreO
Oforthwith
r
erson shall
comply as Oft web provisions or thin permit shall be Jmmd revoked.
^
AGENCY
CONS IRUCTION LENDING AGE
i
a
1 herchy affirm that them ix a conntiucmn Tendon,.,,cnvy nor the pbrriou ce
,
!T7
nI he work lou which his permit is isxd m(Sec.3 N7, Co. C.)
S (:'
Lender's Nanta
Z
Lender's Address'
1 citify than I have read this applicalinn and 'One that the above IlJ Panamint to
ta. E..
correct. 1 egrca m) comply with all city and county oNinaoce and cute laws eluting
to building conswetion, and hereby oehodm reprevnulises of this city to enter upon
the aWvantentim ed property for inspection puyaxe.
H y
V)
fJ Z
IWqugice to save. indemnit'ytmd keep harmless the City of Cupertino against
ladal ics, j.d,n¢ntn, cuss, cud expenses which tray in any way ncerue a,;, of said
City in cnnseyuencc or the granting of this permil.
GU
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POhNT
Issued b Date
y'
SOURCE RikATIONS.
�_
Signalare nl �n� Dante
Re-rool's
HAZARDOUS MAIER1ALS DISCLOSURE
will the applicant or future W ilding eccup nt store or handle hvmdouv material
Type ofOf
nn defined by the Cupertino Municipl tuck, Chapter 9.12. and the Health and Safety
Code. Section 2.553200!
oyes C1 No
All roofs shall be inspected prior to any roofing material being installed. -
Willtheapplicantorfuurebuildingmcupeuseequipmentordeviceswhich
If a roof is installed without first obtaining an inspection, 1 agree to remove
unit hmurdnw air conun inants as defined by the Buy Area Air Quality Management
Disninl
all new materials for inspection. Applicant understands and will comply with
0y" 0N
all non-point source regulations.
I have read! the haruNtns materials requirements under Chapter 695 of the
California Health & Safer Cole. Scoinns 25505. 25533 and 25534. 1 undcrsund that
If the building dues not currently have a tenant, that it iv my reslsnsibility to nifty the
¢enwhen mist be met prior m k saance of a Cenlrc to of
'wpmn of the ¢ytdmls
O,vupacy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Ownmorandmrfaedagent Dan.
OFFICE