00120145 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: 00a0141I
BUILDING ADDRESS PERMITN(l.
/0`j7 Z CE—I S
OWNER'S NAME: APPLICATION SUB DATE
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PHONId SANITARY NO. CONI'Rol.No
G p Z ARCllli'LCOIiNGINHER: BUILDING PF MIT INFO
C Ii1.liC1' PLUMB MECH
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p L1u'llad]DCUN'1'RACTGR'$DECLARATION Job Descri t1011
0y=0 1n emhyunirmroseImnkeenedmolarpnd povi.al cbapmr9f,]anya o,
wFm isin fSeen 11lon7(XXI)nflee,, ,lorthc ifusinc,n vnd vrrnaennnv code.and myliccnw
is;n full loree an effaleM1 / Q /N
M.W<
I.icxnsc�l� 4�1,,� J Sic.N I N
Cnnoncar
ut 5 n-H ABE(((T IiCf'S a,publNA 1)N
io
1 undemmnd my plans shall Ic used as public rcenNa
ki?p Liccmed 1'rofcs,iamd
=wOWNER-BUILDER DECLARNUON
1 nerebr affirm mr
at am a,taud o
fnt Ibe ConoacloCs Liecme Law fn the
C?< following reason.(Section 703 I.S.Business and Pmfesion,Crdc:Any city tar county
2 p
w hich requires.rise nil to aorebruel. her,inarproo,d m rich.or re,rd,may slow,
gaJsm
prior to t also requiresthe pplic t for suchpc in file 'ged statement
thanua,, pursuant Ithe, on-10s,Courra,un,1 La.(Chapter 9 Sq. Ft. Floor Area Valuation
(eummerrIn,with Smtmn 7(XX)I of Div' n 3 of the Bunmeas and I'n ca,ians Conte)
or that he is exempt therefrom and the basis for the alleged exemption.Any stolmion
of Section 7031.5 by any upprieanr far a permit subjects the applicam u,a civil penalty
or not tn,m than rive hnndmsl dollars(s50 ). A PN Number Occupancy Type
❑1.a,awne ohne pmpcny,or n,y enmloyem widr wage,tw mar n,lr,mnpcmmi
will do the work,and the structure is not intended or offered for sale(Sec.70km.
Rminesi and Prorc%cion%Cade:ole conrmamr's License Law does not apply to an Required Inspections
or tof pngrenr W no hailds or Irapa cs thereon.and who docs such work himself
h uugh his own canpny,ea provided mat Inch onpnwemems am oat intended Or
offered for(ale.If.howevei,the building tar imp..carm nl is.old within one year of
1antpletion,the on'nerWilder will have the burden of proving that he did not Wild or
......I,lir"o,"c of oiled.
01a,awns of me pu,,o..an.e,eln,ivelycomaae in,wuh heensed cvrntmmon,m PINALED PINALED
construct the project(See.7014.Business and Profession,Crde:)'IW Contractor's
License Law does nor apply m an owner of property who builds on impmves thereon,
and won eI,act,fm such pmjcm,with t ammaon,)facmed par,atat to the MAY 212001 MAY 2 1 2001
Contmcmr',Lice—l.aw.
❑1 am exempt ander See .Ii A,P C for this mason
Gw°" Date BUILDING
WORKER'S C(ID1PENSNION DECLAHA'IION BUILDING
4P1 hereby instant under penalty of perjury one of the following declamniati
❑ 1 hone and will ardatair,a Certificate Of Consent in self-insure for Winter's
Compensation, as provided rot by Section 3700 of that Labor Code, tar he
perfommme of the wrnk to,which this person is issued
❑1 have and will maintain Worker's Compensation Insurance.as required by Section
37100 of me Labor coxle.tor the Isarromtamc of the work for which this so nnii is
issued.My Worker's Compcnsmioa la-mace currier and Policy number are:
Cartier: Policy Na,:
CEIG RICA)ION(lir EXEMPTION FROM WORKERS'
C.OMPl!NSATION INSURANCE
('Ibis section need nut W enmpleted if the permit is for one hundred dallmc
(51for or Ieua
I cantly that in the pertoiar nce of the work for which this pc r o his red.1
shun not employ any peseta in any manna v a,lot,*xu�e&oje Workers
CampcmatJpl w sy b mi 'L T V
Appncam� I —k a.r �
NOrcu'r(IAPPLICAN'r:ICn1'Icrmaking this Cc 'ntaof Fa,uninq uynu sWuld
III wuhya to the Worker's Can..rnsminn provisions of the Labe Cade.You mast
Oforthwith comply with such previsions tar mil pepon shall he deemed rewked.
r Z) CONSTRUCIAON LPNDING AGENCY
F- ^' I Iwrcby 011mi that mere is a cnnsnuctum lending agency lir tire Ise kamance _
u of the work lir which do,permit is(,sued(See.3097,Cie CJ
0. C Lender's Name
z lender's Address
C.) 0 I enily that l have read mi,applicationand state that the those i altntatioo is
Lzs F' omni 1 agree to comply with all city and county arduuanccs and state laws relating
V lome anbuilding comtmetion. d hereby authorize mpmsetinives oftbls city to enter upon
ry) uMrvcmcmion d property Int inspectinn purpose,
0+ (Wc)agn hi nnvc.i ndcmniry andkhihumayintheCay Cupuniao, nd
V1 liabddies'.judgments,ousts and expenses which may in unY way accrue ugainu saiA
City In consequence of the goading of this permit. �'-7
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT Issued by: )'T"t ►/ p�/--yR/
SOURCE REGULATIONS. y'
Sgmmm of APplirml/Commcmr Date Re-roofs
HA%ARDOUS MATERIALS DISCLOSURE
Will me ir,laum or future Wddingawapam.Ione or handle ha,awr:,material Type of Roof
ss defncd as the Cupcninn Moniaipal C r,Chapter 9.12,and ma Healon and Safety
Cod,Semon 35512(X)!
❑Yes 0N All roofs shall be inspected prior to any roofing material being installed.
Will Ili:a ,Narta,fwarc baddmgmeumnt use equipment or devi=ce which If a roof is installed without first obtaining an inspection, I agree to remove
emit hvanam,air indu n:mu ns JdineJ by lc liar Arca Au Unalllr Manngen eat
I� Diarm all new materials for inspection. Applicant understands and will comply with
❑r=s 0"n all non-point source regulations.
I have read are ha,ardmi, inumials re,miren a rs ander Chaplet 6.95 of the
Calif in I f-1111 Or Sal cry Coda Section,25505,25519 and 25534.1 undcmmnd tbot
if the,building does not currently have a lemon.that it is my m,pomsibility to notify the ! L
occuIf the I immend which must he amt prior rat i,wance ofa Cenifimm of
Gccupa g lure f Ah licant Date
ow r .te.agear Date All roof coverings to be Class "B"'or better
OFFICE