00110124 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
• BUILDING ADDRESS; PERMIT NO,
001101.24
OWNER'S NAME: APPLICATION SUIT DA'I f.
\/ 1
11 /27/2000
to
PHONE SANITARY NO, COM ROL NO.
�Vd ARC]IITECTNIGINEER: BUILDING PERMITINTO
y
BLDG ELECT PLUMP, MECH
F�a 1-1 IJ CI CI
a m= LICENSED CONTRACTOR'S DECLARATION Job Description
ZN 1hereby+Ilimt thin l am rowd ruder provision,of Chapter 9 mismn+ennng
Fin It with Seclwn7Nl91 of Division lIll the llmincn and oll....tons Coda lata my license -
a ^ is in full force and effect.
reow� I-iam,ccmx, Lic., ELECTRICAL PANEL UPGRADE
Dane couloulrr
ARC'III'I ECI"S DECLARA'I ION
g O S 1 understand as,plan,shall be lived m public records
Ser
a a p TO Liccmed Prou"iamvl
OWNER.RUILDER DIiCLARATION
I hetcbY+d'linn thin 1 u unlet Imnt the Cnllm"o",Licen,w Low Ibr ate .
h-;eQ following malaria.Sol 7031.5.Business and Professions Cale:Any city or county ,
a, C which lathes a permit a+conswn,alter,improve,demolish.or repair any xtrucmm
m priormit,lxnmom,akonemd",tire appllemt h—cultlxnniuo fill a signed,tmamYn
3-
that he is Iieemaff punuum to the pmvisionsofthe Comrade.'.%License,law IChapm19
(.a. o" it[,Seclour70a0anry n?nfff,Thone.,anJPrrm..i,n,Coda)
Sy. Ft. Floor Area Valuation
or Irani lou,cacnml Ihacfmm and the hum far me alleged..cnrlian.An,vlohnirn v-
of5ectiun 9031 5 by tiny applicant for a petmil subjects Ibe applicant uncivil penahy
rnmt marc Imre five hundred dollars,S50)P, APN Number Occupancy Type
❑I,as owner of the property.or my employees with xnges as their sole en+npenvtinn. r 7
will do the work,and the structure is not intended or offered for sale(See.9044.
Flows,and Prom..irn.Code.The Coaradna'a Li.eme Law mc,am apply ,,ton Required Inspections
of pmpeny Who hull&or improves thereon,and who does such work him,df
vx Through his awn employees.provided that such imparvancms art nor intended or 304 — ROUGH ELECTRICAL
offered for sal,.It,however,the building ail Intpnrvwne ,is ,.to willon our year of
iompletion.the owner.budder will have thelmrdcn of proving that he did not build or 501 — FINAL ELECTRICAL ENERGY
mprove for purpose nl'nale.l.
❑L nse
as owner of contracting with licensed cnnlractrr,n+ 505 — FINAL ELECTRICAL
+muun tireLaw
Deproject(Sec. to;ill
Busies,and Pmmvhiom CIXIor 910 ves m.mr'.
Ind rkeWho
Law Joe,not apply m rot rwnw of a pertyrenal who builde sed puns u,thereon,
and who contracts fm such pmjeas with n commce+gsl IiacnuJ pursuant to the
Gmtmcurts License Law.
01 am cxnnrnnnlcr Sec. .B k tic fur this reasou
Owncr Dmc v
WORKER'S COMPIiNSAI ION DECLARATION
I thereby odium mid,,penalty of perjury one of the following declaration.:
❑ 1 have and rill maintain a Cenifcam of Consent m self um for Worker'. +
Contpvmation, as provided for by Section 3700 or the Labor Cute, for the
perlornnn.c IT the work for which this I,conot is issued.
❑I have and will nn+intaio Worker's Compensation Imumnce,av required by Section
3700 rf the Lalwr Code,ser the perfummince of the work or wmuh miv Ixouit Is
ivsucd.My Worker's Compcmaion Inwmrxe Cartier and Policy number arc:
Carrier: Policy No, -
CUR TIpICA'I'ION OF EX EM RODN FRONI WOR KIIRS'
COMPENSATION INSURANCE
('Mis section need not he completed it the permit is fur one hundred dollar.
($100)nil less)
I certify that in the perloor ance of the xurk lin w hich Thi,Ixrmil is issued,I
.hall ort it Ir,any per.on in;my manner.0 as h+Iwesme subject to the Workem'
Ctnnrenvmion Law,of C9lilba+ia.Date
Applicant
N(rrICE'r0 APPLICANT:IL al'er nud.ing Thi,Cenul.me of Eacnt,a I.you should
become subject In IM1e Worker,Com�nsatian provision''It the Labor Code.You lint
Q O forthwith comply with such provisions or this wormil.hall be danced revoked.
z �
f" h Chin here
nsLction NG leading
a } 1 herchy allium thin ps,00 is,nmamnien Ietuli Co.Cxy lin th.perfomunc
W
or the work fur which Wis permit i.issued(See 3097.Cv.Cd
L ❑ Lemicr'.v Name
Z bender'v AJJm,
C.1 (:) I certify that I have read This appikod I and'Stam that the aMwe imbrmmion Ix
4. F. comet.I agree to comply with all city and county ordinances and state laws mining -
U mbWlding conxnuction,and herchyivahonm reprcxenmtivev of this city m unser upon
} h: the ahovom ithimed property Pur orpenion purry+wx.
rM. (Way agree to save,indemnify and keep harmless the City of Cupertino against
(A I'mbilllln,judgmonls,.e.1,l I evpenas which roily in;illy way accrue ag;Linsl sail
city in.answers of the granting of this Fern+it.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POTM Issued by: Date
SOURCE RLGULA'I'111NS, y'
Signature of ApplicanUContranor Dam Rc-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant lin future raiding cecurant.sore or handle hammaus material Type of Roof
as dehned by the Culxnlnu Municipal Cale.Chapter 9,12,and the Ileehh and Sim.y
Cada Section 25532(a)'1
❑Ye, 0N All rool's shall be inspected prior to any roofing material being installed.
W111 the app0.man'ham'c hdddirg aCmiplan Use rcpdmncn or devices uhclt If a root'is installed without first obtaining an inspection, I agree to remove
each hm.Nuus air contmninnms as dcfnN by the bay Arco Air Quality Managcnxnt
Dimriea all new materials for inspection. Applicant understands and will comply with- °Yep °No all non-point source regulations.
I have rend the haeardouk ocam is requircuentx under Chapter 0,95 of the
CulihnniuIlcullhit,Salary Cis le.lection,25515,255331 t25534.I undemmnd That
if the buildi r,does ma currently have to tumuo,that it is my re,folobilu,m notify Ili,
xcupatn of the requirement,which most M net prier In i.wmes of a Cei ificam of
imct9nn". Signature of Applicant Date
Owner er mAhoomd rgm,t Date All roof coverings to be Class`B"or better
OFFICE