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--- _ .. • OFFICE
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION:
BUILDING ADDRESS:
PERMIT NO.
21267 STEVENS CREEK BLVD
01100007
OWNER'S NAME:
APPLICATION SUB DATE
JEFF CARVER
10/01/2001
PHONE:
SANITARY NO. CONTROL NO.
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ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
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L ELECT PLUMB MECH
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LICENSED CONTRACTORS DECLARATION
Job Description
1 h arm dill am littnsed Order forms Wain of Chapter 9lcommeneing
001 Diri>iun icorthe Buainecs PmfnsionCo femme
DEMO.
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with Seuf of cold s , .idmy
is in once and effect.
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ase Clae. _ ue. x%
oIt comm"m-
AHCllln SDECLARATION
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I unJcrsunJ in, Plate shall W mcJ ns public remNa
Professional
pLittnsm
OWNER, RATION
at
1 hereby viSee shat 1 e.p,E from the License law for the
from she Cession,
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ions Code: Any easy or county
1. , Business Cook:
following anon. 7031.5, Business and
C
ve de
which rtquimx o permit [o rnnarucl, alcor, improve, Jnnolish, or repair any svuvmrt
permit to
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prim) n. uitt, 1. reg the appla'mllmsvch pcm[ilmfkaugnm s[memem,
_ .. _ _ _ _.-_____ ___ _
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) Sq. •Ft, Floor Area-a \T
4 '" ' '< 1, `Z '' I 'e fl' li
a Uat100
:
sharne' 1 eased p rc ant to the provisions of the Consmnols License lax IChapmr 9
]1)(101 f Div 3 Professions endo)
Item m ng,wnn Scmm� ascot 0l e a kiia ea ave
or that he is acmpt [hcafrom and the basis !m the vllegiil cadmpum[. Any violation
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of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
Of nm mme than Five hundred dollarsf WI,
32 111
A Kq um erOccupancy
Type
01, as net of the pm,ury, or my employees wain wages as their sale emmpemmlun,
will do the work; and the-strucuum is not intended or offered for sale (Sec. 700,1::
' Busincii and Professions Code: The Contmcmr's License Law does not apply to an
.
Required Inspections
mcne, of propcny Who Wilds or improves Bari and who does such work himself
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or through his own employees. provided [lint such improvements as not intended or
- - - -- I -� -.--
offcad for ad.. If, howmef, the building or improvement is sold within one Year of
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'
me owner-Wilder will have she burden of proving that he did not build or
iompletion,
mpmvc for purymc or sale.).
f9l. as owner or the propeiy7., ezdusivelycomraning with laterad convenors to
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c on.amct the projro[ ISm. ]Di,1, Business vnd Professions Cmc:) The Convacmr's
-
License law J«s no apply man owner property who builds improves thenar,-
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with s
and who commcu for such projects witM1 a.comraclonsl laterad Wnmm to the,
-
Cure rauors Lianre Law._--�'-
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0 lam exempt under Sec. �0&PC for this ..on
-
Pre, Datc •'• .
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WORKER'S COMPENSATION DECLARATION
I hereby effort under penalty of ve jucy onv or the following declarmions:
0 1 have and will maintain a Cerodicxe of Con.wm'to self-insure far Worker's
Compensation, as provided for by Section 37M of the Labor Code. for the
perfmnnance mf the.. for which tris pc.pit •is issued.
01 have and will mairan n Worker's Compensmion Insum«e, as mquiml by Soct ion
37M of the Labor Cmc; for the pertmmanc< of Ihiwork for which this permit is
[sue].'
orker's Coion Insurance carie; and Policy number arc:
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't•''�Ss�l�ls cTsti i(i �C •b1Lv [: [„fix. ': :rL 1
';CERDFlCATION OF EXEMPTION FROM WORKERS'
s4
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u'
' (Ib i scn'uiri mem amt be cmnpleie:l ane pert[ I is for cone nundmd dmlkrs
i'°sl I`• 111.11 ••: � l n; t , ,Illi 1 s'
($Hu)1. lessJ
-
mnn irkr <n n rteI .
I certify that [ 1 R K -. td.l
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Ii t.S iP`-it Cl ,t .a `_.. h .' t..
^. ..s'e,
shall [ e pluynn y mon' t b) I to he workers
e'
Cmmpcnsauo fB:,
.
Applicant - - .'E ' .
B chi I o"'E
NOTICE TU A LICA : If Epyou should
• s s "u' 1+ 1':
t pens
itsubjectm the Worker's Compensation the Lalror Cmc. you mull
Oboli
forthwith comply with such provisions ur Iris permit shall he deemed revoked.
^.In
' CONSTRUCTION LENDING AGENCY
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form,
I I hereby iffnnlhm lntne is a conomr,inn lending agency
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„pedo,mlana
oftewokorwhichthispetmil
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rel
1certify that 1 have read this .,licmion and sum Inco[he obova infonmmiom is
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mie, 1 agree I. ..,Iy.wilh all city and county b nem ad.t t relmin,
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to Wilding cI Ionand h byau[honz presentauves afthis cityto enter upon
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the clause-ancatomed pr perry for inspectionp rpm ,
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(We) ague, ) grt 14"t. Memory id kt p harmle ry [le C 1 C pen est
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I' biI I judgments, cost, d eict whvh to ny ora) g_ino Id,
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City n he B rm' p t
U E ST S\NOs 0 P WITH ALL NON POINT '',
APP
Issued by:
RCEaE , .tC�_I_0`
sienamrco ArdicvMCnmmc .,- •` ."' Date ",..
Re-roofs
'
HAZARDOUS MATERIALS DISCLOSURE '`' •'
.,' Wll the appliiii[[or.f win Wilding«c pant stem Hamel hazvdus mm nal
Type of Roof -
s def d by the Cupertino Municipal Code Ch pt r 9 12, end [M1 Health al Safety
Cine Sectio255331x) I a •
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❑Ye:'''•;^•^,;...,,;' n\
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Y All,roofs shall be inspected prior to,any roofing material being,installed.. , _
'-Will theupplicemuilLlure but ding«cupIaml use I.of de-vins which
If a roof is installed''without first obtaining an'inspectio_n' Il agree40 remove
emit hazardous air conmmini I defined by the Bay Area Air Quality Managcmem
Di,'riet- - , ,..,,,, , . ., .:.
all new materials for inspection. Applicant understands,and will comply with
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all non- oint source re ulanons,
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1 have he
[Safe, ordims menta" d 255 Chepter'erst
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and Lundcrsmm that
California actions 505. that
k Safny Cme. Sections 251;
,
i i. at it is ,,mci
iGlne n.1 d« acumen hese.¢ 41h'fima.y mspnnsibili[ymnmify the
'e'
'occuppm '1 rnis ie u' ries prionb'issuande'ora CeniMme of
a
Signature of Applicant Date
All roof coverings to be Class "B•' or better
m pa a I Dme
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--- _ .. • OFFICE