00110099 CITY OF CUPERTINO
nun.DING DIVISIONPERMIT CONTRACTOR INFORMATION:
BUILDING ADURHSS: PHRMIT No.
OWNMCS NAME: APPLICATION SUP DATE
rijPFRTTNniL' IP17100
1 PHONE: SANITARY NO. CON'IROLNO.
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0 ARCH]'1'HCULNGINCHW BUILDING PFRNUr INFO
;y HLDG ELECTPLUMB MHCH
a�E 1_1 I_J CI L_I
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Z S N hna that i s CONTRACTOR'S DisionRATION ,lob Description
�m41 1hcnby mlirnl that am ufO,dander Prov ision,of CM1C le9(u,mmecense
Fu� with tall lot,, nddllej, iUll?of the lL;.incss;aN l'mfcsxion,CnJa:nW my lkcnxu
d � i,In lull Emcc aIW CIIiyy�,,
d a T,tacn,u cm,_ YJ uc., 210 103
F w" nate_u.�l] _C ' Contacnr TAZ ANTENNA
ul 3 ARCHITECT'S DECLARATION
t= I unJenwnd my plam,hall be used as Public ncards
w O O I imnxeJ I'ndcasionlll
c d
GWNHR-BUILDFRnlfr UGChARAnoN
FFi= I hereby a0inn that 1 am exempt fmm the Contractor's License Law far the
F followins mason.(Section 703L5,business and Prole.ion,Castle:Any city or coumy
f ❑ which requires a nonoil to consume,tiller,improve,demolish or repair any.sec ore
Pr ort I 'Ifo y aIplln f I1 nils 11 .'g Jsmtun cu'
e
bar be 1,lacriscdn ...tl In m pro,ima;.x I he c t .orsL 1. (chaplet) Sy. Ft. Floor Area Valuation
(comtneremy with Section 7000)of Division 3 of the❑odn.s and Poll...iod,Calc)
or that he is exempt therefrom and the basis for the alleged exemption.Any violation �.
of Section 7031.5 by any applicant for u pemtirsubjects the applicant a civil penalty
of not tnam than rive hundred anE:.rs 69ap. APN Number Occupancy ype
ID].;is owner of the propcoy,or my umpinycc with wase...n lher,"'le.... en,alion,
will do the work and the slmcltue is not intended or offered for stile See.7W4.
Hnsmns add Pmfmsions Calc:The Contructnr's License Use does not apply to air J , CCIUIrcd Inspections
.orthr of propeny Who build,or impro,ce thereon,and who dots such lark himself
rough his awn employee,provided that sunlit intpro,ements are not intended or ?04 — ROUGH ELECTRICAL
altered for,sule.If,however,(lie budding or ing,nwen,enl is sold w'IHan one year of v
mlpeliun,the n so,r-t Hider will hove Ihv human oI PmvinR Titin bit did n I build or
improvn hnpapast,of sae). 501 — FINAL ELECTRICAL ENERGY
0 1.in under fthe posting,and eschoisel, ,oronnfin,with licensed orstract.,1. 505 — FINAL ELECTRICAL
nrtmct the project(Sec.7044,Business and Professions C.de:)ITc Contractor's
Liucnw,Law does sol;"'Iy In all owner,of propwty who build,u,improves thereon,
and who nnanter,Inn'xudl po,c.l,wall a coo trawl... Lcen.cd pur.nmu to Iha
Cnntmclnr',License Law.❑lumcxempnce, Se.. .Nkl'C fur thisnmonEXPi
owner DateR i),
WORKHR'S COMPICNSA9'ION DFCLARA'1'IONI hereby..1 inn,ander penalty of ne,j.,,one of the folbwing declaratO 1 have and will maintain a CenlEcaa of Consent to sif-insum for Worker's Camycnsatlun, as provided for by Section 3/00 of the IaMn Code, for the
perli,n lance of the work for which did,1ern,it is i.sunl.
1 h:Ise and will n,aintuin Worker's Con,va.atina hu,omuce,as required by Section
3801 of the Lwr Code.for the I,,rfinnounce of the work for which this pcm,it is
issued.My h'.�C,mpenmtion insurance carrier and Policy bundler arc:
��/�
Carrier:
�uyVy I,— Policy No.:W C2-&Z I�(/
g Y1!1121H CAI'ION OF N1?MP'1 ION FROM WORMIRS'
C'OMPHNSAI[ON INSURANCR
(This section need not be completed if the permit is for me hundred dollars
(SI W)or Ims)
I...lily Thal a Ills perlbnnunca n1'Ibe work In,which this Inrmil is i,,ard.I
shall not clop.,any person in any manner so as In become subject to the Worker:
Compensation Laws of Culifnnal.Dole
Applicant
NOTICP.TOAPPLICANI':If,afar making this Cell of f?xcaTion,you should -
we ane x ihjeel to the Worker's C(ou,n%llion provisions of the Labor Coda you nom
Q fonitwilh comply with such pnw siom ur This permit.hall he dwnl,d revoked. -
F tCONSTRUCT ION LENDING AGENCY
I hereby affirm tot there is a oa,wnion lending agency far the perfntmanee
Wul'the work for which this permit i,issued(Sec.3119).Civ.C)
C6 Q lsndcr'n Naov
.7 z Lender's Address
V C I cenity that 1 have read this application and state that the aMde infamalion is
E.. arreel.1 agree to comply with all city and county ordinances and,tate laws miming
Q U labui ldi...o..inatian.and hereby atuhorim representatives oftbis city do enter upon
>, 19, the abovcmmno.ned PI'upcny lin uu,se,Jnn purposes
r gL (Will agree no 1;111,indemm�y amfkee,Looks,(he Cayof C'opcnmo agah"I
to liubildws.judgment,.cast,clad eyaa.c,which,may it,:toy way accrue against said 11 M
I.) z City in consequence of the granting elf this permDaIC V
it. 0
APPLICANT NDER STANDS AND, COMPLY WITH ALL NON-POINT' Issuedby'
SOURCE UI U `
Signatnrc ¢nhCandun— _ -1D8:.12.— Re-roofs k
IA%ARDDGF NU FLI IALS DISCI-0: Rli
Will we applicant or future wading occupant stare or haadle ha.ardou,aatcdd Type of Roof
as derided by the Coleman M.aicipal Code.Chaptar 9.12,and the Health and Solely
Code.Section 25532(0)!
eve,, 0N All roofs shall be inspected prior to any rooting material being installed.
Will the apprienot or wore lmildin,tweap:mt use c,.ipnaml at devices uIii,h Ifa roof is installed without first obtaining an inspection, I agree to remove
emit hazardous air cnnlmninan¢as defined by the Bay Area Air puul'ny Management
District' all new materials for inspection. Applicant understands and will comply with
0Ya, ElNo all non-point source regulations,
Ihail,reed Iha h,,;ndou ... est.un
x. iuls rel der Cln,ac,695 of the
Cal itornin Health A Sul'efy Code,Sections 23505.25533 and 25534.1 understand Thal
if the wilding dors not currently have a¢sant,that it is Iny responsibility In notify the
,xcurym of the requlremens which must be,met prior to issuance of a CcniH<um of
Q� N19 -Signature of Applicant Date
own. harl.fd„gen,, time All roof coverings to be Class `B" or better
OFFICE