00090127 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDINGADDRESS: PHIL MTINO.
OWNIiN'SNASIH: — —Mj a _W) DEVLIU14 UUNIMI HLJU 1I'1'I If1NS
01 e7
`HONE: s •.. SANITARY NO. rY
❑K Z ARCHITECT'/ENGINEER: C— G UILDING PERMIT'INFO
i9O C ❑LD EIxC1' PLUNIB MECH
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uu _I I-1 I_I 173
z N LICENSED CONTRACI OR S DECLARATION Job Des ptic
Et,• I hereby alliin that 1 not IittnseJ under provisinnn of ChaPmr 9(commm�cing
F T111"with Seminn71kk11ufDivinio 3ofthc3Lata poSDECLnRAI[ONa,v INTERIOR DEMOLITIObI NCHITECI"S UIiCLARAl10Y1 under a_,�,.ns shall be used a.public records
c. cJ n"T
ff OWNER-EUILDIIR DECLARATION
i5= 1 hereby alrno that 1 tarn racmnt froln the Contractors T.icen.e hw for the
F y c which re reason. eorat n]tin LS. t,alter.
ss and improve,
dcanns Cotic:Any city s county'
Ee" Fioal q ' p nn n t h p 1 r:n i >: eture
a�� n''n t1 lm [.pr rt 1l 'n ll 'g d.nl tem
mat! lunadpnau Il mepmn tet. frit C...anallor,L I Iclaprer9 Sq. H. Floor Area Valuation
lunnmencing wise Secumn 9aq)of Uivisinn J of the Ifusincv and Proleoim s CnWo)
,,,,bar he is exempt therefrom and the basis for the alleged namptioit Any violation
of Section 7031.5 by any applicant for a proton subjects the applicant to it civil penalty
tonot m111than fila nm,nrcddolmrs65doi. APNNumber - Occupa$c$QfgjpQ?tQi
C 1.as owner onhe propert,or my employers wise wages as flair sole eompen..almn. .
will do me work.and me%loware is not intended or o fend for sale ism.nw. 31621 089teGlifV'ed Inspections
❑tsiae%s and Professions Conic:The contractor's License Law Joe%not apply in an
,, r of pmpeny who huilds or improves noreon,nod who dux:%such work n'nnsclf
,though bis own employee%.pmvlded that .an Improvanentx one on,Inlcndcd or
uttered for%ale.IL howeverhe nodding or impmvcnmm is sold wimio our year of NO ASSIGNED INSPECTIONS
considetion.the e b IJ II have the burden f pausing that he did not build nr
narrative too p n r 1 i
C I f not pop q siv 1, loolin,with I' I . ,. ,nrr In
Lm t thelijeer(s 7094 R i ncs and r Ic% n%c 1 ) Inc tracnnr%
icanse Law does not apply it) rofproperty who build,(it irotp e.Ihemon.
and who"attracts for such pmjmns with u connections) licen%eJ pursuant u,ser ��
Curtwho %Loren,,ors
❑I sen eacn,pt,ode,Sri. .H&P C,u.n nu.
Owner Data
W'ORKER'S CONII-17NSATION DECLARATION /'� '
I hereby aynnn tousle, ltwty of perjury ooc,l the following dccmmloo;; LLL
I I have and will ntninmin a Certificate of Consent m mlf-insure for Wodars
Cnmgensonion, as provided for by Section 3700 of the Labur Code, far the -
imrlltrro nce of the work lin which this pennon is in,ucd.
C I have and will maintain worker's Coltiv—don Imurance,as tribunal by Senlon
371X1 of the Lahr Code,lin me performance of the work for which nhia permit is
is% .MAyy Workdv Compensation lnsunmcc carricrand Policy n maser art: -
cmdenpAa_Sctr—iA4 Puli"No,: (ud�97m£%yp— .
CRKI IPICAI'ION OF EX13NIP'I'ION FROM WORKERS'
COMPENSATION INSURANCE
(This.section need not be completed If the permit is for one hundred dollars
6100),,less.) ,
I cenily than in Ne performance of the work lin which this permit is issued.I
shall not employ any person in any inner so an to Income%ubjwn to the Workers'
Cmnpcmalina Lows of Cablonsia.Dare
A,,,Urso!
ND IC=.10 APPLICAN'n M aher olaking mi.ConlEnac of HacnrptionYou amuad -
M1ecnme sahjert m the Workers Compen.1m.puskior,of the IrM,r Code.you nmst
Q O b,nhwiN comply x int such provisions or this permit shall be dcaned revnked.
CON S'rROCTION LFNDI NG AGENCY
7I hcrchy affirm that thou is a ennslmnio I Troon agency to,I'o,the per orntmmc
la: of the work for which his permit is issued(Sce.YNl,Civ,C.)
Q I.cnder's Name
z I.cndds Address
U C 1 tend,That I have lead this op,locan a and.ante thri rhe ahoJc immnn:alou is
Ca. = correct.I agree to comply with all city and county ordinances and slam laws raining
Q U us building coronation.and hcrchy authorize representatives of this city to enter upon
the ahovcmontioned property for inspenton pmts'.
1 We)agree to save,iuderarity and keep hamdrvs the City of Cupertino against
h livbilhiu,jrdgnmm%,costs and eysensesc which ln:ry in any way accrue again,,.said
U "L Ci "A"lqN`r NDERNc granting ol'nhis permit.
PLICANT UNDER.ST SAND WILLCOMI'LY WITFI ALL NON-PoINT Issued by: Date
OURCE Rr:GU S. 4'
. goalurrn nrtm nate Re-roofs
HATIsRDOUS MAfENTALS UISCLOSUNIi
Will the applicant orfmure building occupant umemhandle hveNuus material Type oof
ns JefineJ by the Cupcnuu,Ntunici,l Cale.Chapter 912,and the llcalth and Sufny
Cado,Senn 25532Ut)1
CYc. 0 N AI roofs shall be inspected prior to any roofing material being installed.
Will Ncapplicann or rmurebuilding occupant use egniprmntordeviceswnich If a roof is installed without first obtaining an inspection, 1 agree to remove
cant hmmdous air conrantinars as defined by the!ivy Area Air Quality Management
%Trim' all new materials for inspection. Applicant understands and will comply with
0 Ye, 0 N all non-point source regulations.
I have mad da hmallous materials requirements under Chaptar 6.95 of the
California Tlmlth&Safety Crene.Sections 25505.25533 and 25534.1 understand Nut
building seas sen currently have a renonn.Thatin is my re%pon%ihility m nollfy the
cupunl of nhc l'egnl emu which inu%t be n o poi n n,isms n.c of a Cecilwanc of
occupancy' a Signature of Applicant Date
q–20 —oZs
Iwner or almori.ed agcttt !lata All roof coverings to be Class "F3" or belle,