00110019 CITY OF cuiTFINO ll
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: Co040 / 49
8GELDING ADDRESS: PFRhfl'F NO,
OowNER'S NLrl ;�00 STEVENS CREEK BLVD. AAAA-nROTnI n
tIflr ' nprl.lcnruNsuBnnfr,_
"ws: I_INION CHURCH OF CUPERTIMO ] 7�'l] S 7TH ST SANITARY tJO] /03/c¢iILI°III"O'
C] ARCIII I'ECD'IiNGINEER: l BUILDING PERMIT INFQ
SiL-�° (408) 989-6005 BC: ELECT RCT PLL UME Mu
S2y
y LICENSED CONTRACIOR'S DIiCI.ARATION Job Description
oz—p I hereby of nnu thm I not licensed nada pruvisiom of'Ch:m¢e 9(cnmmcneing
uJ with Sea an 701pl o1 Division l nnhc.Be<Lrle..and Pmfra.iom Code,and my license
a C fall fora,seri.11,11. Jle
yYRJ n 7 6
s� Liccnsc Clas .—J� Lie. L /V
o d _ll � an:tral FqZ
u, a Ar RcTllrlscrsnec1.ARATION SEWER PERMIT
C— wrotr,itA al Plans ball n,usM:m PUMic¢Gush
ao c:e n t :. I
OWNER-BUILDER esm,tr UI Cc ARAI CormIQN
W m 11 so ft d'l l p l th C or. License f f..the
t—> which g .IS 1 t c ver B .' r, W professions Codc'Any city only, / -
Ice e0
which y R tl c t n alter, Ir I I:M1repairya .sore
µW print to issuance,also requires the applicant lot peat it to de asgned emlete ,
a. mal he is licenswd pursuant o thepm.tsinrt of the Comrai License Law ochapter 9 Sq. Ft. Floor Area V<Oil
fen ing with Santos 711g11 A jus n 3 of he Bas and dd
Prafctund Code)
or that he is exempt therefrom and the Iasis lin the alleged exemption.Any violation
of Section 7031.5 by any applicant for a permil oobject, be applicant Io a<Isil penalty
of not more than Esc hundred dollar,(S501)) APN Number Occupicy$Type
❑1,as owner of die propcny,,,my employes with wns,s ns their sol,<n upe-mum, I
will do the work,and the%mature is not intended or offeml for sale(Sec.7044.
prime's and 1'rofcssions Crile The Cnnlmclor s Liccaw law docs not apply to an quired Inspections
owner
r of property who builds or impresses thereon.and woo does such work himself 3162609
LIVJ
or rough his own employees.pnwided tom such impmvemonts arc not inu tided(it
offered for sale.I1,houecc the building or improvement is sold within one year of
imm.fictin,the ownenhakde,will h:wc the rumen of proving that h,did not nom it
prove for pulse of sale.), 106 SEWER R WATER
CI 1.as owner of the proper,amexclusively eonewaingwith licensed contractnato 202 — UNDERFLOOR PLUMBTNG
Laulm,l the project(see.7(144.ILrvin,es and Prnfcminns Cuda)'Me Comment's301 —
iecnw Law does not apply to an owner of properly who builds or'aniproves thereon. ROUGH PLUMBING
an
Com Zwhoia',License Lawcommas for such projects with a comrD)licensed pursuant to m` 302 — TUB R OR SHOWER.
❑1out exempt under See. .B&P C for this reason 502 — FINAL PLUMBING ENERGY
OwnetDale 506 GAS TEST
WORKER'S COMPL?NSA'I'ION DECLARATION
I bercby opine tinder Pen:dty of perjury one or the following decimations: 507 — FINAL PLUMBING
0 L h:mm unit will raintain a Ccrolicute of Consent to scll imsurc for W,)rkcr's
Compensation, a. provided for by Sccaun 3700 of the Labor Code. for the
perfnm once of the work fns which this permit is issued.
❑L have and will maintain Workers Conmed%aliun Insurance,as mIuimd by Section
37(X)of th,]..No Cuda,I the perfmtnancc of the wurk for whleb this permil Is
i...red,My Wirkrrs Com n mien noumnce carr^/d Policy number arc:
X Camcr. �� N 7 Policy Ph, 3 X19
/ \ CHIGIVICAI'ION 01;E%I!MPI ION FROM WORKERS'
COMPENSAI ION INSURANCE
G1,i.s section need not M completed it the permit is for one hundred dollars
IE 100)or le".)
1 certify mat in the perromtance of the work for which this permit is issued.I
shall not anploy any Peron In any manner♦o as to hceonm sahpci ,,the Worker,'
Comp,nsaion laws o1 California,Dam
Apph,anl
NOnCE TO APPLICANT:If,after making this Cimmi ce of lixemplion,you should
hc,o .subject em the Worker's Cuntpemminn pmmaim
, s of e Ymmoo
the Labor Cade t
Q O Ilmhwim comply with such provisions or this permil doll he dimmed revoked.
F N CONSem is
L1iNDI NO lending
ageAGENCY
C ? I hereby affirm thin them ids construction lending agency am the perfonnunee -
of me wed Iia which this permit is issneJ sex.4097.Civ.C.1
Lcndcr's NamP, Addu' Z Lender's AJJress
U Q I coily mut 1 have,at(his up,dwaljon and sane that the alone inh nnntiun Is -
f. p correct.1 agree it,comply with all city and county ordinances and state laws elating
Q U to holding eamtn¢alon,and hcmhy out hove mEnewnunivcof this city ,,enter.,at
} ry] the athove-mentioned property for inspersion purposes.
(We)agreer:sou,indeami ty and keep hunnlcar the Ci ty of Cupertino against
lit!) liabilities,jud&nems,costs and expense'"
xUlh Illayin any way accone against said
V Z City in comwqucnre of the gaming,fmi,per f n
APPL.ICANIUNDERST lD WE 'eN1 PLY WITH AI.I.1,0 I- o T Issued by: Date
SOURCE REGULATR S. /,/ J y'
'signmurc ul APpucan tar l `/ Dam Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
WE the applicant er future Mnking tacapmn atom or handle lm ardaae material Type of Roof
w d.rord by the Cal,ni Municipal Cods,Che ter 9.12,aid the Health and Safety
Codc,Section 25532bm!
°Yes " All roofs shall be inspected prior to any roofing material being installed.
Will the applicant orfuture bundingucapant use apApmem ordevicas which If a roof is installed without first obtaining an inspection, I agree to remove
mit hmanim,air Unnannuaninam,as deaned by the]toy Amt Air Quality Managemni
D,ismal all new materials for inspection. Applicant understands and will comply with
ElYer all non-point source regulations.
1 haoc ream the hv:mmur materials regnimnantn under Chapocr 69.1 of the
California Hicalth&Safely Code.Sections 25505.25533 and 25534.r understood that
It the huildmg doe current ly hnvenyrLLux.ahat it is my respmsihility to notify the
.upant of t ymrc mow whic rlGel won prior In issuance of a Cm lir to A
(lca:pane
Signature of Applicant Date
o
5,,nerr- tr,ri,edagrnl I tc All roof coverings to be Class "B" or better
OFFICE