04110039CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
772 ;zTP.1TP.NC:
ERMIT N0, 4110 0 3 9
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NER'S NAME:
PERMIT ISSUE DATE
ONE:
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG EIF.G7 PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby Chapter 9
Job Description
affirm Nn 1 am licensed under provWons of (commencing
with Section 7000)of Division 3 of the Business and Professions Code. and my Become is
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la fens LicenseforceCls a1W LRCCI.
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TI--NOODLE HOUSE
PIN
Daems
Dem Contractor
ARCHTfECsS DECLARATION
1 anMmand my ptau shall he uwtl As public records
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Licensed Pmressiooal
OWNER-BUILDER DECLARATION
I hereby a(Tm that 1Aexempt from thCommune, Lice
ommm n law for M
?0
following nown.(Sagan 1.5, Business ad Profession Coe: Any cityor roomy
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which require a permit mwwm
ccl, almr, improve, demolish, w repair any mumuro
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prior al its Issuance, also requires the applicant for eIXh pClmit IO BIe a signed elammCw
that he is licensed to the of the Contractor! License Law (Chapter 9
Sq. Ft, Floor Area
Valuation
pursuant provision
(commencing with Section 7000) of Division 3 of the Business and Prokesines Code) w
a
that ha Is ampt thenefrom and the basis for the alleged uemptian. My vlolNnn or
t\
3 6�5[®IDIfbe1O 0
Occupancy
P Y Type
Secdon 7031.5 by any applicant fro a impair objects the applicant in a civil penalty or
nal ream than an bus dmd dollars (xs I
0 I, u awnwaf He propmy, w my employee wild vara u Ihh we mmpewdon,
wan do dmwon aha 0" ora fro We (Sec. W, Business
tan es
Required Inspections
and Profession ease: The Cmntrwmrs Ld mored
Ucbm law saes oak apply m an nwner ar
he con up
.
property wh who his
propertywhobuildsviimpwvu Hereon,endwhosussoastwork Montin
man wehlmprowmwaarc not edreroute
formlethe
however. the i pr earof ompleered
the owner-
He building or improvement is hath within ow year of compmp Owner.
Wilkehowever,
for
bullderwill haw W bmNan of proving that he did al build w ImProw for purpose of
ase.).
0 1. as Owner of the propeny, am exclusively convening with licensed conuacwrs an
Construct the project (Sec. 7044, Business and Profusion, Cade:) The Convaeors U.
awe I.A. does am appy in an owner of progeny who della ar improv Hereon, and.
who contract for must pmjecta with aeonbMmr(s) licensed puruunk to He Conuse ar's
Lk"na Law.
0lan Am un S< B&PCf the won
ner -C
WOR CER'S COMPENSATION DECLARATION
I hereby e1Rtm under penalty of perjury ane of the following declandons:
I haw end will maintain aCcNOesm of Consmam celbiuu a forMiters Compere
udon. u providrG for by Section 3700 0( me labor Code. for the performance of the
woe for which His permir is toad
0 1 haw arM untw
will mn Workers Compensation insurance, u required by Sdon
_
3700 of me labor Cade, for me poor.. or the hawk far which Hu permit is issued
My Work"%1l Cyompemado Insurance curia and Polity n ase: (/
Carder: 1-/'(tel/ , A Policy No.: I 91
CE COATF OFEKEMMON FROM WORKERS'
COMPENSATION INSURANCE . ro
rrhtawai nwedmtr complemdif;I.MnnhHmrowhundmdd llw ($lm)
or less.)
I certify that In the performance of the woe fro which mis NMI, is issued, I Nall not
=play any person In any manner an as an beCOTe whiner to the Woraps' CwopelWdw
Laws of CW fomiu Dam
Applicant
NOTICE TO APPLICANT: If. afour making the CeNRcae of Exemption, you should
bettme subject m thO Workers Compcuation Provisions of me lahw Code, you most
forthwith comply with such provisions or His permit shall M decreed invoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that mem Is a comncdnn lending agency for He la rfammwC or
the work (w which this permit Is Lamed (Su. 3097, Civ. C.)
Lenders Name
/
Leaders Addw
1ttNe doe1how dos application and sum Hu the Above infestation in
arrm I arra m amply hath all shy aid cowry mditwwor and rota Ire
idn
building endoneddom and hereby authorize r upon t e
of mis city m corer upon the
show• purposes.mpmseramtiws
paternity ny for Inspectionkeep
(We) hid City
(iju agree to an, indemnify and kap hay In m the City of against
Inconacquence fthesou and expenses which may In any my wane agalna aid City
')
Of Hh permit.
APPLICANT
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
UNDERSng TANDS
JI
Issued by: Date
SOURCE REGULATIONS,
Re-roofs
Type of Roof
Slrnuurt ofAppliaDM
HAZARDOUS
HAZARDOUS MATERIALS DISCLOSURE
WIII the applicant or (ulurt building acupant sort or Medk haurdous material
Asdented by Use Cupertino@, Cupeno Municipal COChapter 9.13, and the HoM& and Safety
sae, Sming, 35533(.)7
All roofs shall be inspected to any roofing material being installed.
Gees ON.
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building aeupam use equipment or dc.Ias which
mit stannous air contamlunta As de0ned by the Bay Area Air Quality Management
all new materials for inspection.
District?
Gees 0N
I ham reed me haraNtwsmamdals inquimmena underClmper 6.95 of the Califor-
nu Health & S+fckyCodc, Somlau 25505.35533 and 35534.1 oMcraaid that irate building
deo trot eortently haw a tanant, mu it u my responsibility w adfy the Occupant of the
n:yulmments which mug m met Prior w iuvance or a ccNficee of occupancy.
Signature Of Applicant Date
All roof coverings to be Class "B" or better
0wner
or mthoriad agent Dow