00110035 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDROSS PERMIT NO,
P1470 IMT —`c
OWNER'S NAME: APPLICATION SUIT DATE
Pv
lovio - _ SANITARY NO, T NTIt L o.
BUILDING PERMIT INTO
p AItCHITEC'1'/ENGINIiiiR: BLDG ELECT PLUMB MECH
zU� lJ 1� Cd Cl
�¢y
LICEhatI CONTRACTOR'S ULster,of Chard
Job Description
I,i,)n 7 ),,f Inn,I not licensed under to aced iann,if nv Code 9 anmmenemg
0=�0
iI Pan s in
nflJivi,ion3nl,hc❑nsinc„unJ 1'rufea,iuns Code,and troy license
z 6 Ln full l'urru and ellen.
icense Claes a Lie.p
o nw,u Date commemr DEhIO OF SFDWL
I ie u y ARCHITECT'S DECLARATION
Iu.° I u.dr,,and my Nan,,hall be used a,pubre rceoN,
�r
w or C�O Licensed Professional
d%aer OWNER-BUILDER DECLARATION
ul= ' I hereby affrnt that I:nn exentp,from the Contractor's License Law for the `
G ¢ fnllowi,or,en.se,lio.70315.Bu,ine,,and l'rnfes,inm Cde:Any eilyorcnunty
O which requires a Penni,u,construct,alter,improve,demolish.or repair any amemre
ca p°or to its iemencc.also"Print the applicant fur such lM^niuo file a signed,talcsent
Imo,he is nettled puntmm to provisions of the CoumactorS License Law(Chapter 9 Sq. Ft. Floor Area Valuation
(cnmmencin,will,Sermon 7Q)0)of[)Ivlslon 3 nt Joe Broin,,and Prot e„ion,Code)
or that he is exentp,tM1etefnnn and he basic Per alleged e,elnption.Any violation
of Section 9031.5 by any applicam for a Perard subjects,he applicant to a civil penalty
,if not ,methanliveltumdreddunun(E5Br), APNNumber Occup n y e
lt
❑I.as owner of the pmleny,or my employees with wages a,their sole contpensmlrn. '
will do Ile work,and the structure is nm intended ur offered fur de(Sec.1044. ';D Vj e'a ' 9
Business and Professions Code:*no Cnnlmetors License Law does not apply¢)an gUlred Inspections
nit p,oRrly Who I ild,or niprn c,becau,and wl,doe,iron work himsell
ior though lie own employees provided that such improvcmcns are tot intended or
otrchW for side.If.however.,he building or improvement is.sold within one year of NO ASSIGNED INSPECTIONS
completion,the owner-builder will b:tve the burden of proving that he did not build or
u.pn..c for purpose of mlu.l.
r of,he proles¢ant exclusively contracting with licensed contraction,o
a,msec,,he project(Sec.9(114.B.,iness and Pndas,irns Chde:)The ContrdO.1” 7�
,i a Law docs sol apply it)an owner of property who build,or improves hhereun,
.oda who eoun all, for cull p ajecu with n non c'un')Iimn,N pumas,n,@e
Con,tucur's License law.
❑IPon
caempt under S«. .H&PC for,M1is salon .'
Nowncr{_ t_&W )-re
Y (1 KL 'd COAL IiNSAr10N DECLARATION
I herchy allirm under a Ce of perjury one of nM1e following rca'Ia r Worker's
C I have and rill provided
a Cenilica¢of Consent t sdfansme far Worker's 7 r`•
Compemwtion, he work
for lir by Sections issu of ,he Whim Gdc. for ,he
Ixdbrin;mcc ofthe work for which this permit is issued. - -
01 have and will mainmin Worker's Colnpemabou Insurance,u,required by Section
3700 it the WM,r Code,for the performance of the work for which this permit is
sued.My Wurker:s Co r,so ,atou Insurance curter and Policy number arc:
Cartier: Policy No.: s
CERTIFICAI[ON OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
(This section need n.I be completed if the porno,Is him one hundred dollars
(51 W)Par IasJ
I cosily that in the Iwrlimn:mee of the work for which his Penni,is issued,i
shall not clmplioy any parson in any lo,un,r si as ,,hennne subject to the Worker,f
Compensation Laws of C.Iihania.Date
Applicant
NOIICIT'rO APPLICANT:11,:dam Inaklng this Ccniri,a c O Cmc nuion,you should
.ketone xuhj... ,,In,Worker',Coro,usutisimiarsol he Lab...C
rdk,o.you inu
Oforthwith comply with such provision,or this permit shall be deemed revoked
fCONSI'RUCI'I ON LENDING AGENCY
I herchy mean that'hero is u cmwumcalon lonJing ogenuy tor he poribnnauce
of the work for which this form,i,issued(See.3091.Civ.C.)
1 Q Leader's Name _
Q 7 LcnMr's Address
U 0 1 certify that I have mad Ibis application and state that he mane information i,
I,. F. cornet.I agree to comply with ail city and county ordinances and state laws elating
0 V tohoilding cin.anstiori,and hereby a.do6m dc,m,wncujray.,"I this ciry to enter.,in
[r (y he ubuveanannloned property fav impceliion purpose,.
. IS, (We)agree to save,indemnify and keep hairdos,the Ciyof Crpeainoxgnim,t
rn liabil'Ite,,judgments,nets and eapen,es which stay,in any way decruc against said
U City imcion%'quenacoft1m partin,ofthi,prour. �(/\ �1
APPLICANT UNDERS'IANDSAND WLLLCOMPLY WITIIALL NONIssued by: Dial
e r
SOUV�{Tg F'C 11.ATIONS. .•�� a�
SignethAc of ,pheaw unnanm 1 to Re-roofs
HAZARDOUS MA'IERIAPS DISCLOSURE
Will the applicant ior future hP,Jding«cupunt store nr handle trmrdom nourdel Type of Roof
is defined by the Cupertino Municipal Csde,Chapter 9.12.and,he Health and Safety
Calc Section 25532(x)?
❑Ye, ❑No All roofs shall be inspected prior to any roofing material being installed.
Will the apprcan,m future huddin,(et topant use equipment or devices which If a roof is installed without first obtaining an inspection, 1 agree to remove
oemit hairier.,ser aonmatinum,m defined by the Bay Area Art Quality Mared,emem
Dlsmna all new materials for inspection. Applicant understands and will comply with
❑Ye, ❑No all non-point source regulations.
I have read the h:vaJous nuneriuls rcgiiremenu tinder Chapter 6,95 of the
California I ittdti A Safety Qdc.Sections 25511.5,25533 and 25534.1 understand that
it the building doe,out cut....flv hove a tP liar to a ny'e,on.sibilily n,no,i1'y the
«nlpan,of the requirement,which armor be met prior to issuance nit'u Certilicme of
Occupancy+ Signature of Applicant Date
owl„ a�fi1`'^N- 11-`�'-I �,e All roof coverings to be Class "B" or better
OFFICE