01050171 CITY OF CUPERTINO '
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS Pf RIIIII No.
1' 50171
OWNER'S NASD.. 36SIEVENS CREEK APPLICATION SUB DA'Z'E
PHONE!
_ _ SANITARY NO. CONTROL NO.
z z AItCHD'IiCT/IJJGINEER:
BUILDING PERMIT INFO
O❑C❑ BLDG ELECT I'LUMIi MliCll
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�m u, LICENSED CONTRACTOR'S DECLARATION
4` Iheren Zinn that l am livenwd under f coater 9(commencin Job Description
y a provisions o r g
°�F° wild scunm,7n(ro)urDld%n,n3 anna Baine,,curd Pn,fexni,n.cWu,and my r<enxe
e^< is User
e fullli,rccantidlec IA`--s`[td.Q��-[•J-I
��< "are rr, "�S�q RELOCAT.E'a ELECT I CALIs
axj S LL N Dal[
Aplane os shalI'IiCIl "s DIiCLARATION FINALE D
nuJernnurJ my ,buibe o,,d a.public record, i
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w t`Ii ne p Llemrenl V'Lore"ional
OWNER-BUILDER DECLARATION r,I 0 2001
e uai h I herchy affirm Ihot 1 nm OxLem,from the Contractor',Liecow law far the JUN YY
t Z< following ma,on.(Suction 7031.5.Bw,ine,T:nd 11.nfi.•avion,Core:Any shy ur county
'Fc which m,mm,. .it o f t,do,improve,d Lh p ., knocuum
ce
acI 3pr, t . I. _O 'III' II Inch It fl 'g Llmmmd
c. that he is licensed ptl hep v III he contractor,LiLa (Chprer9 Sq. FL Floor Area DING Valuation
(cu nmwslrg oth Seednr 700(b nr Div sen 1of the Bu,me,s and Pmm fc,,iaCode)
or that he is exempt therefrom antiInc basis for the alleged cwmp+ioa Any vielnlion
of Section 7031.5 by any applicant Into permit%objeas the applicant m a civil penalty _
of muniore Bnot B,c hundred dollar,($500). APN Number Occupancy Type
01,as owner of the propenR or my employees with rages as their sole campuroation. _
will do the work,and the vacation,is nor intended or oficmd for sale(Sec.AW ,_,
I. G '.-C. '-
Bnsim,:+nd Prernsion,Code:The Contractor's Licei,c Law dons not apply to an
squired Inspections
r of pngnny Who builds or ruprovcs thereon,and who dues such work hinnott
oror his own employees.provided that such improvements am not intended or —. ROIJ6H` ELECTR:PCAI a
olhoed for sale.IL however.Bre budding or imp,uvement is sold within enc year of -304
complmlon.the owncr-baiider mill have the hurdennf provinglhm he didnd hard ar 501 — FINAL ELECTRICRL ENERGN.r_
impmvof purpowofsale.).
❑I.a,owner ofthe prnp<ny,,mexclusively contracting with licensed contractors to 505 — ,-FINAL: ELECTRICAL :,
mamct tireproject(Sec.7(94.Boone,and Profession,Code:)'rne Conlmcle"s
License Law dons not apply to an owner of pmRny who build,or improves thereon.
oma who commas fnr each pmjal,wield a amtmao,, Iieenxed puntra,nr the
Comracme%Licen.m law.
O I am usmmp.under Ses. .ii&P C for his reason
Owner Data
WORKER'S COM PUNS A'I'ION DI!C I.A RATION
I hereby allirnr under pr nah, d pc,11ury one of the following deelmalion,:
. 0 1 have nand will nmlnu,in a Cenibelue of consent or.self-inure fur Wtnw,,,
Com,noatian, a, provided fnr by Seelion 1700 of the Lahor CuJc,'lor tlm
performance of the work for white this permit i,issued
01 have and will maintain Worker',Compenvtion Insurance,as na,nmd by Seainn '
1700 oIthe Labor CoJc,for the perlimnance of the work for which thin peril is
issued.My Nbrkei,Cnm nsation hr,uruntt carrier and Polity numhr arc:
f i
Cartier., 1 4 arV-G P�+EeyNo.: iC411SD11r1_$ OJ_
CERI'IFICSRON OF CXEMITION FROM WORKERS
COMPENSATION INSURANCE
('Ilii,scalnu need not he...mplcmd it no,permit is for one hundred dollars
($LO(B or less.)
1 mmdv that In the"nonnunce of the work Ln which dais pernril is issued,I
shall not employ any person in any manner so as to become subject to the Workers
Con......d m Ls,,of Culifnnia.Dula
Applicant
. NOI ICli'it)APPLICANT':IL ORO making this COrficam of Escmplion.you should
became object me worker's Cnrrrpen,mmar prevision,of the Lahr C,dc,yea moa
Q Q onhwith comply with such provision,or this permit%hall be rescued cooked.
z
F V] CONSereisa ONLii\DINGAGC:NCY-
�' Ihk fee afire,that Ihaei,s csued(Sm. knell ngagency fnr the pede,nnnncc
W
Lender's
work for which this peril is issued(Sec.7tYi7.Civ.C.)
z Lerdcr'v Numo
� Lenders Address -
U 0 1 certify that 1 have read his application and stale that the above inlorn irroo is
Gs, F., caned.1 agree to comply with all city and county ordinance,and stale laws relating
V Io Wildmgeorumuetlon,and Inchy mnhuriI.reprele ONe,or this city ,,eforupon '
� rya, the aMwe.inemioned pmpeny far'-,peed--puHnaes.
' 6s (We)agree m save,indemnify and keep hnmJess the City of Cupenioo against
h liabilities,judgnmms,costs and expenses which may in any way accrue against said
C,7 Z. City in commlucnccofthc granungof this permit.
APPLICAN'I'UNDERS'1'ANDSAND WILL COMPLY WI'OfALL NON-POINT Issued by: Date
SOURc arrLs'or /�
sigrralv�m�o1ALImi ermor--ontmaLnr 1 Re-roofs
HAZARDOUS NINFERIALS DISCLOSURE ,
Will the appficanl or I'mum hullding weapanl are or handle hvmdous mmed:a Type of Roof
as defined by Jre Cupertino Municipal coule.Chapler 9.12,and the Health and Sale,,
Code.Section 2553230"
o Yc% No All root's shall be inspected prior to any rooting material being installed.
will he applica t or future buadiog rcaupand use equipment or devices which If a roof is installed without first obtaining an inspection, 1 agree to remove
cavil ha'eanka sur connnninam,as delined by the Bay Area Air Quality Managemrnt
• District' / _ all new materials for inspection. Applicant understands and will comply with
0Ye, c�'`' all non-point source regulations.
I Lave read the hoaardou,material,rey^iremenn under Chapter 6.95 of the
GII'dorma HCxllh&Surety Core,Secio ns 25505,25513 and 25534.I mnderstand lm
if rhe building dares not currently ha%c a mount,that it is ory resmmsibility to nolidy the
,CCupmn of the rcnoi rcmcnts which must be nal prior m ix,u ince of a Certificate of
/ Signature of Applicant Date
Tt ,_ ,�e S/t7�e 1
Oxneror moluaimd ugvol ! DA All roof coverings ro be Class "B"or better
OFFICE