01010045 TY OF
crBUILDING DIVISION
NNo PERMIT CONTRACTOR INFORMATION:
BUILDING 158, U '4rgR.,FLAND WAY "" r 1.0045
1158
OWNER'S NAME: APP&T py l/tTho 1
SHU, DARREN / 1 / L LI,$pLI
IIONIi: SANITARY NO. CONTROL NO.
zZ ARCNI RiCI'/IiNCiINiiER:
BUILDING PERMIT INPo
RLIyG ELECT PI-0MII MECH '
N d IJ I_—I 1.=J CI
Fyj LICENSED CONTRACTOR'S DECIARATION
Iarms,affirm mitt l am licehual under pmvisiomof chapter 9 monnrmdng
Oo�C
Job Descriptionr4 ail will,S,ai.n]Clunof Dwiiun 3.t fluenoailiexxaml Pr,te..i:,n•C..de.aaloty deen.e TEMP POWER
G<.j^j la in full forward etfim.
ap Lissom Class L fc.M
3 a N nine Comrocmr
CIfI'
AHI'ECT'S DECIARAT ION
t 01 i andermantl fry plana xmdl be stied a,pumir record.
w d O C Lianmd Pmfosional Li /
c%o OWNER-RUILDER DECLARATION V
ace_ 1 hereby affirm that 1 am exempt tram ntractor'.the Coscn.a Irw to the /
l V=a following reason.(Section]1131 5,13mincss ant Promioons Calc:Any city or county
Y�o which mquim.,a fermis u.aor,nm .aIle,Improve,denmlish...I.fair; y m ualmc
a 3 er priors t . W thef suchpc permit fl Ked statement
s t,Ire i, ' IP ' nI,'he x I he C I t sl L (Chapter9 Sq. Ft. FloorArea Va�jlation
(commencing with Suuon]al(gtr D' ssn 3i the ltu inw and. f.-.ion,Cwte) Y11
or that he is exempt therefrom and the basis for the alleged exemption.Any violation
,,I Scar 1 7031.5 by if,:gmlmnnI f n a,,e nin x,,bj,c,,the afpllannf m a civil penally
or hat mom than five hundred dollars a500n. APN Number Occupancy Type
01...owactor life n.o,to employees wire w:.c=as thei—oleenln lion. 36603065. 00
props y ycmP Y g Pensu
will do the work,and the swcture in not intended vo Law roe.ale(Secy to an
owner
and eny Who b Gate:Tnc rovesContraclux-vo .and w Law Joel not apply m an Re .wired Insp@O t 10[15
tush his
who builds or macron.and who nisarehwodbded or 304 — ROUGH ELECTRICHL
nr errough his own employee..eroded that such...provasmnu are net intended or
cfrmedfor.the. wmer-veocr.me noiavethe burden of is ]it within am gild or 501 — FINAL ELECTRICAL ENERGY
`uprove far the owner-builder will have the burden of proving that he did not IwiW or
Itmrooc an parlatw ofaalc.). 505 — FINRL ELECTRICAL
°1.as owner of the progeny am exclusively contracting with licensed aomraaocs m
nn,,.tat she Inotecs(Sec.7044.Itusines..mold I'wfesslons CnJup The Contmnor's _
License Unix Jces not apply to an owner of pmlzny who builds or improves formal.
and who contracts lin.such project,with a utmmnons)licensed forward to the
(mlrucmr'.I,Icen.c LrW
int urd _ �I 1'0—
It
I is masnn
D n 0
xenn It Y.MI iNSATI(IN
cr I hereby affirm under penalty of perjury one at the following de.0lar+tions:
° 1 have and will n aintain in Certificate or Cnnwal Io W11i-cm rnr Worker's
Compe.sninn, a, provided for by See, n }]al of the Lola. Calc. for the
pcdlnnn nci of the work lar which this psnnil is issued.
°1 have and will maintain Worker's Cormemmdion Insurance.as required by Section
3700 uI the hfrox Code,fur the air.......aWe of Ibe mod lin which this punnit i. '
.sued.My Wmkm%Cungcnanion Inwmwnce carrier and Policy number arc:
Carrier: Policy No
CERTIFICATION of EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tills section need nod he completed it the peril is for one humdmd dollars '
y1hot er less.)
I certify dint in Ibe performance of rhe work for which this permit is is%md.1
,hall nod employ nny person in any manner so as ,,Inaction,sabjecl In the Workers'
Cimmerian..Laws of Gdifomia.Dale
APPIIca d
NOTICE TO APPLICAN-E IL after making this Certificate of Exemption,you should
0 heconm subject to the W'ader'spenror
Comxatirn provisions ofthe lalCale,you most
Q tonhwim comply wilb such proviaona ns DJs Woo t shall be deemed m—lard
z .
CONS em is it ON LENo len AGENCY
' 1 hereby affirm this mean i.s rnued I.
. lending C aFcncy for the perfornunce
If. of the work for which This penin is issued(Sec t(n].Civ.CJ
5 ❑ U[alander',Nmne
� z lender's Address
U O I edify mal.have read this a....nal lon unit slate inn line above int at r is
:r. F., ememi.I agree u,amply with all city and county ort inane,and Stam laws retain,
O I,,mAlingcor,ruoinn,unit lnamby autneam representatives orshiscisy m enter upset
he ahoovanensinnN mwpeny for inspection puTna•..
IWe)ugme a,save mJcmnify nnJ keep hamtlosthe City of Cumenmo again•
lip II ilhicx,juJgn.....,cols unA expend.which nary in nny wry awnm against,aiA
U z C c. 'dense nr the Forming of this pvrmin.
A
ruL�vd'u y - Nits .Lcomr1.v sur u,.ruo -�1K Issued by: Dat
a',ornp -nV mnmcor Dm' Re-roofs
oNARUOUS MATERIALS t wore yS and.
wtl he e Cupertino oe more ipalCo.e.chapter 91 to hamate ni am.ms Said) Type of Roof
m se.Sec by tire 32(m.'no Municipal Code.chapter 9.12,and the Hwhh and S.tlisy
Calc.Section 25SJ2(u)':
°Yea 0N All roofs shall be inspected prior to any rooting material being installed.
W911 the applicant or future budding recall use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
nit heuMous uii von.anihait,as def ned by the tiny Area Air Quality Managmnna
istfnel] all new materials for inspection. Applicant understands and will comply with
°i'°' °N° all non-point source regulations. '
I have read the b , a
a,undo merials requircmem,under Chancr 6.95 of the
CJifornia IIcailh At Strefy Cale.Siren is 255115,25533 I d 25594.l ond...find mat ,
it me building does net currently have a tenmR that it is my resmrnsibilay to notify the
cupam.f the require rivals which�in I pilar ,,isymn o of:n emiree of
f ( Signatureol'Applicant Date
d m—¢ All roof coverings to be Class "B"or better
1.Ile
OFFICE