00100088 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
IluanwcnnDRE.as: pEVCON CONSTRUCTION ''f'INI:NO' 001000$8
19925 STEVENS CREEK BLVD C
OWNER'S NAME: 555 LOS COCHES S f APPLICATIONP fh YAM 2000
PRUDENTIAL INSURANCE CO MERIC G
'40 HONE: c40$1942—e200 SANITARY NO CONI ROI.No.
�O AHCHITIiCflIiNGINIiIiH: BUILDING PERMIT INI'(y
pp BLDG CLIiM PLUMB MECH
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FN L1eHNseucaNTHd....I sOIicLA oI clu, Job Description
Z�O I hmnby ulEnn Nsn I nm Ilcemal under Prnvisinn,ut Chtmmr Y Icommenaing
mseni,.n7axpmtDJyy:inn3mineuu.c,o...nnePtysy,nd ducen.a TEMPORARY PERMIT
�' in full foreeand eft t <(`d
�s� hicenw('a,�
D Iy:uc V l /7� mtnor
u1%Icy ��It(�(]fti DfCI.ARA1 ION '
=
[understand my Plam,hull be used as public record, -
-ega a y I.wemcd Prnfc„innal
OWNER-HU11.13ER yC1ARA'IION
'u5 m I hereby affirm that l ant exempt inunine Commnor,,I.Icense Low Iia the
C?Q kill.wirg reason.Slid n1703 1.5,llmmv,,and Profession,Cale:Any city nr county,
which requires a permit to construct. Iter.improve,demolish, R y lincture
ag
i3= it t 1 otos y rare,dieupplicarn for suchrental filesigned autuncat
11w1 I Ip to Ill 1I oV I I I ro Ot I I I c f III,] WIWPIe-9 Sq. Ft. FloorArea ' )l'701D0
(eoamenemg with Seen 7(olfiof Division 3rat the Noshes,and Proko,i mCale)
or that he is exempt therefrom and the basis for the alleged exemption.Any violation
of Section 7031.5 by any applicant for a pennil subjects the applicant to a civil penalty
n art hm,m than five numhed duh"as(E5'H0 AP 3 j uu .,' ��Zt$9. 00 Occupancy Type
O I,as rax net of the property,or my employees with wage,as meir,ole emry,em:Non.
will do the work.and the.fracture is not intended or offered for,ale(Sec.70,l14. 1'pfr��,.pp fQrryf ���yP(f1 It'
lint ,cad Pnde., m,code: the Covtracmr:Lieenw Law dues on apply u,an 304 — RO V Vti IrgL I K Y LAL
orof pmpcny WIin I Ids mprrs,lhereon.and why&w,such work himself
thrrough his own mnpluyces.�pnwmed hart such iinpmvelnenu are mal imended or
ollered for sale.If.however. he building nr improvement is sold within one year of
completion.the ownenbuilder w ill have the harden of proving flem he did not build or
Improve for mr,,, a ale.t
,a1, (if the property, siv IY contractingwi11I I o t In
L,n,t t a l sen IS 7UW o es- on R k.. ,n,end ) up C tact s
ae I n:split rill pre puny n Woad r s thereon.
C:ar h t o. for protects with t t (u7 I p t o the
Cn 1 iL:
mn
❑1 ora exept under See .a&I'C liar this mason
Owner Date _JOQ
WORKI!R'S COMPENSATION UECI.ARATION
4001 hereby affirm under penalty of perjury one of the following dcdurations:
O have and will maintain a Ccnihcam of C,Ownl to wif-u sure for Workar's
Cninpersation, a, porvoed for by Secion 3700 of the Lnhur Code, for the
pedonnance of the work far which this permit is i...ed. ^
❑I have:md will maintain Worker's Comlenwtion Immune,as acquired by Section - �•/Q
7700 of 1h,Labor Ctale,or the perl'ormansc of the work for which this parmil i,
issued.lily Worker's Compervallom Insurance carrier and Policy number am:
Cameo Policy No:
CERI'IFICA1'ION 01:EXGMPIION FROM woRl, ills'
COMI'IiNSAI ION INSURANCE '
(This section need nut be completed if the permit is for one hundred dollar
($100)or)ess.
I ecrlify mar in the perfon.mnen ,I the wink fur whim Ells Per r,is i..mId.1
,Hall ant anpiny any person in any manner so as to hwous,subject u,the Workers'
Cnmpervaimo hes of California.Date
Appl cant
NOTICE'1'l l APPLICAN'1:It,:dor mnking Ibis Cenrcme of E ra......o ynu should
race,ubjem to the Wmkcr',C...l"i tua n pmvlsions of the Labor Code,you must
0 Forthwith esnaply with such provisions or this pontis shu11 he deemed revoked
F = CONSTRUCT ION LENDING AGENCY
I Itemhy allinn that there is a con,humu lending ugancy Inr the pc tin icalo
ilI the work pia which this permit is issued(Sec.3097.Co,C.)
L Q 1<ndds Name
Q z 1-ander',Addres
f..) Q I certify Not I Ince real]III,upplicmion cad atam Ind the above informal'um i,
E... correct.I agree to comply'wish all city and county ordinance,and slam Lsw,eclating
Q U IU Wilding construction.and hereby emha 7c representatives of this city m enter upon
the abnvoowareaed pmpehy liar I,,,too purpose,.
Ey y IWjudagree ts s costs and
It'and which
harmlesstheway rcrueninoaga aid ("�
V1 liabilities,judgments,sou,anJ eslense,which may in any wry ucemu against said / (J
U Z. City in cnme"IND of Ne gremiAg of this permit.
APPLICANT UNDE STAN PND WILL COMPLY WITH ALLNON-POINT Issued by: Dat
'SOURCii HEGU /�_VC1
sigomumof�me,m rah Re-roofs
n",Ih000S bIATIiMIS V NIZ"tS..fi
Will the applicant cr nature budding occupant smm or handle na.:odous omental Type of Roof
I,dohncd by the Copertino Municipal Code,Cll 9.12,Ind the Health and Safety
Cale. enio 25532(01:' ON.
All roofs shall be inspected prior to any roofing material being installed.
Wi11 be applicant or Innate building occupant use equipment(it devices which If a roof is installed without first obtaining an inspection, 1 agree to remove
anis haaoslous air enulmniran,a,defied by the IIay Anna Air Quinn,Micro, cal
hstdc
01'e, 0No' all non-point source regulations.
1 hove Ictal the h:vmdnus Inmerials rctryimmenls ander Chapter 6,95 of the
CaliforniaHealfir& ft'Chulc.Seniors 25505,25533 and 25534.11mda,madlhat
if the building dues not currcndv have a lemon.that a"any re,gmsibility u,notify the
aceupm t of the ou,iremen 'ch must be met prior to issuance of a Cenificuta of
G°capancy. Signature of Applicant Date
act ormithmired age - Date All roof coverings to be Class"B"or better