00070179 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS; PERMIT NO.
/ OWNEWSNAME. APPLICATIONSUB DAFE
UNIT: &WITARI'N C R L O.
O ce% ARCHI'FEC'LENGINEER: (408)927 OS60- BUILDING VERMD INI0
O❑O HLDG EI-ECI' I'LUMB MECII
suU
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z anm tionLICENSEDCON'nRACTOR's DECLARATION Job Description
m I hereby ulfrnn Than am frolieR anal.pmvi5io...obee:yrer, a'olmnrnein,
F„�u wdn secaon anl>tn mfDiviaien3orntr aa.iaexr aha rmrraalon.erste,aha my frrm.v
a j f Is in fun fora n erc
Yin < LianS�cln,.c��---"sL o� Lir.a�7 Z \ A/C
D L ale_(�,/yo+ enmrnetm Op
ARC III ECI"SI '! LAR, 1(.yl_a1
—y 1 undersand my plans shall M rived as punt t
ra ap O licensed Prol'es.ional
E OWNER-9UILDER DECLARATION:: 1 hereby..Bonn that 1 am exempt from the CourtraiLicense Law for the O
F in Y following reason.section 7031.5.Boom a and probe.'.......Codc,Any city m county O
—2=
Which requires permit iI I alter.rallove,denioloh,or rcrarrany stricture
�t-� prior lot also W the applicantI - hpermitl II signedNm
atcent
e, but he is licenser[final tthe pravionars of the Contractors L L (Chapter4 Valuation
all will,Se.......vono)of ui' of3 onhe Rndne..anti Pmfr..i..rixCoae) Sq. Ft. Floor Area ....tion
or that he is exempt iherefnna and the basis for the alleged exempllon.Any vlalinion
of Section 7031.5 by any applicant far a permit subjects the applicant to civil penalty
of not more than live hundred dollars($5UU). APN Number Occupancy pe
01,av uwner of the printery.or pity entployro with wal a.their...le vour,amluar.
will do the w'srk,and the xwaum is not imcndcd ,,offered fill sale(see.]IIW. 32 64 1 il
Bm.inc...;aid 11 1...ton.Code:'lite Cmtlraaor.Llceave Law does a.,apply to an Wquired Inspections
,asnarol pfmpeny Who ani ldx or improves Ner.on.and who duns such will,lino ll
or through his own employees.provided that such improvements arc not intandal or
offered for.ale.If,however,the bunting or improvement is vole within now year of 303 — ROUGH MECHANICAL
nmplmlon,the ownerhuilder will have the humeri of proving that he did not build or
improve for mepowol sate.). 304 ROUGH ELECTRICAL.
01,a,owaer orme property, at exrlasi rlr contras:..,w,h licensed runtmanry In 505 — FINAL ELECTRICAL
Lrmlrnel tic"neo",love.matt,an.inav,and P,,,I..1..11,Call.)The eommaor. SOB — FINAL MECHANICAL
icense I.aw dues sol apply nt nn owner ob prrperly well hulld,or impnwcv lhrrcom.
and who cotnmets for such pntj tts with a contractors)licensed pursuant In the
Contmaor'r Licoave Law.
0 I ant ,ainqu under sic. .n&I'C For tlhv ,a..
Owner Dae .
WOR]r COMPENSATION DECLARATION
in,
1 hereby affirm under penally of perjury,one of the following declarations:
J I hnvc and will maintain a Certillcnlc or Convent et self inure for Worker's
Compcn.alion. civ provided far by Section 3900 of Nu Lahor Code, for Ne
perfnnnanec el the work be which this permit is issued.
❑I hnvc mrd will maintain Worker's Contpemandon Inxurancc,m reyuircA by Semina
3700 of the Labor Codc,lir the IWO..rmm�ce of the work for which this penin Iv t
ssud,MY W'der n npcn<alimt Insurance comer and I'olicY numMr are.
CaY. nilewu 1, f,NoA2�461�L9 E
CERTH'1CAd]ON Up IT Mill ON FROM WONKENs'
COMPENSATION INSURANCE,
(Thi,nactien nein air be contplefeJ or pemtif is fur one madbal dollars _
150N0)err less) -
1 certify that in the lnroati ance of the work for which this permit is issued,I
ah:al nm employ any pre.un is any a as to hsbs�m aoorcet In(lie Worker .
Conultennm Laws of Culifo me nso
Apphcam _
N-anne o1 1To he ..IL agarmaking this Ccrifcait of Laboro... or should
Incomeh comply Nesuch pi Gmtpe or thin PmviCtin,it%bille calor Cached nwxl
Q O
forthwith comply with asM1 pmvisiom or this permit shall bedanwd revoked.
F y CONSTRUCT ION LENDING AGENCY
I hereby nffm.thin there is a mauuction Inidia,agency for the parformeave
of the work for which this permit is issued see.3047.Civ.C.)
Q
Leader',Name
.7 7 Leader',Address
V C) I cerify that 1 have read this application and eine that the chose information is
la+ [- corwei.1 agree to comply with at]city and county ordinance.and Stam I sus relating
[� to buikim,......rucli... and hereby anhi representatives of this city to enter titin
Ise uMwe-nmntlo..ed pmpeny lir morelliou purpose,,
}Fi pt (We)agrce to save.indemnify and keep harmless the Cityof Cupenino again.
V1 liunilhicx,judgmenu,cosh anJ uxpenm.which may in anY way accrue again•said
U Z say hrconxeynrnre of u,r gram ..nix m,ntta. —f
APP I.CANT UNDERSTAND. A ) OMPLY WITIf ALL NONPOINT ISsDCd by: DJto /.�( IrCJ
SOU .RE
o�gn o,npvrenm/c„rimae. Date Re-roofs
HAZARDOUS MA'1'IiR1ALs DISCLUSURIi
Will the applicant or future bonding occupant.tore or hou r ha.awtax malerial Type of Roof
n defiled by the Cupedinn Mnnicipul Code.Chapter 9.12,and the Health and Safety
Codc. Sevlla 25532WC
iC3 No
All roofs shall be inspected prior to any roofing material being installed.
\ruff,cappueanlormluranniminat.e..purl...eyaiporcntordn.ice.Which If a roof is installed without first obtaining an inspection, 1 agree to remove
moot hnmmous air comaminanls fes ddlaed by Inc Ray Area Ain Quality Manmgcmenl
daria'r all new materials for inspection. Applicant understands and will comply with
❑Yes 0N all non-point source regulations.
1 have read the hvamouv noun edals reyuimnumis and,,Chapter 6.45 n1'lir
/ California lleallh&Safety Code,Section.25505.25533 and 25534.1 understand that
'f the huidingdoes sol anciently have a rara 1. hill it i.uny rasptmsihil hyla notify the
ecupam of one rcyui"'nenl,wii,b moa Int men prior w Invnncr of a Ccdilicuta of
Oe`epaa`y' _ Signature of Applicant Date
Owncr or nor bodzcd ngrntt D.ur All roof coverings,to be Class "B'• or better