00080158 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT No.
2017,135 VAI I EY GREEN DR SOI ITHBAY CONSTRI I :)IS, 00080 158
(VINER'S NAME: a APPLICATION SUIT DA!E
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SANITARY NO. CON]Rol.—NoT
oof
Q z z ARCM" CfIG N.ER: BUILDING PERMIT INFO
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O zy- LICENSEDCONTRAC'IOICS DECLARATION Job Description
H I hereby allinn,hot 1 am IiccnscA under rmvistnnn ell Charnel 0(cm„ Icing .
w 1_w withsoclion7al1)11Dhi' 3ofthe Bodnes 11'olc riot sC c n liaxme
is in full force and eller
Eisen Cb Lic." TI/DEMOLITION
d.a.U Dale T_ S DEC
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Fn ARCHITECT'S UECL\
I undemmnd my plan.•hall be used as public records
g O Licwscd PmfcaiomJ
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OWNER I are BUHAEIr UECe C...n TION
1—=�w 1 hereby (S0 c nuc am esen,p,tram lib,C,,io.,Col License Law tern Ire
H 7 Y which ng mmnn.(3cction A1nstr t.alter,mW Pn,lde o li h,or Any city lir ternary
^`z p which mquircs a permit m mmwm,cher,improve.demolish,lir repair any>wetnre -
a, priono its iswance.also nalma.s me applicant felt such permit to rile u.sigmeal statement .
that hells licensed forward m me prevision%of the counselors license law Chapter 9 Sq. Ft. Floor Area Valuation
(commeneing with Section 70x0)of Division J of Inc Business and Prolcroions Cale)
or that he is exempt therefrom and the basis lis the alleged exemption.Any violation
ell See,ioa 7031.5 ray any uppll,am for a Pcoal mhjecte the upplicum rs a civil peralry
el oolmor"ho riseboodreddolmts(s5t0). APN Number Occupant
C 1,as owner of the prolwrly.or my employee.with wages as their side con,pensenon. .
.ill d..the vePer and the amewre is not mended lir..(fared fur sale sec. to70,W.an 3L. r
mim,of ane erty Will, Code:Till, vonmctnt's License Law eces not ork h m an lteyuired Inspections
r of his me cno Wild,or ovidedn at such and who Jocz such work himself
thecalthrough hal awn employees. Wilding
that such inWent is sold
arc nm inn ear or
tratefur sale.Ir,hohuddethe buavet lirhnpmvctnco,nsola within one year lir NO RSSIGNED INSPECTIONS
completion,for the owc of-1c)
will have the burden of proving that he dice lit nail)lir
improve for pamtsa oracle.),
C I,a owner of 11.e....lrny,atm,xcln.ivoly commetin,with licensed conpnch rs to ,
.s the p i ',1St 7096 B s.s I 1 ns C' 1 111 L ..co n
Corson,
,ice
Lowdar,o f imply ly t ne of prrpcny who WrI,L or improvestherm,. \6%
and who f c,. for such projects with a crontractims) licensed puromen to the
Connector's License Law. J
C1 I am exemptuJ Sc .B&P C for this rent
Owner Dam -
WORKIik'S COMPENSATION UIiCLARATION
I hcmhy of iirnto N,,,weahy of pcllnry lnc ofthe following du9amtinns', /■.��
El I.... n
uvc and will t In on a Ce,iiEcn¢of Consent to n,I.ar,mc lar W..ker's V
Compensation, a ......idled to by S„tlon 370() tf ,be.Labor Calc, for ,he
rfnnvncc of the wad,or whicbh
, is permit is issued.
I have and will maintain Worker's Cnmpetermion Insurance,as.inquired by Section
701 of the Labor Gale,for the performance of the work for which this permit is
t I t M kers Cel all..Insurance carrier all Polis
Carrier' �fC(/M/_/L�_Policy No:
ERIIFICN I( OFE%EMIT ION ( 1KOk
COMPENSA'T'ION INSURANCE
(This section need not he completed it the rental is for one hundred dollars -
u10)7
I renal,Ina,in the Pel ermanee of the work fur which this permit is ismed.I
shalt no,employ any Person in any manner so us to hccnin,subject in the Worker,'
Compensation Laws of Culifornw.Date
Applicant
NOT CH TO APPLICAN p11,ah,reking this Centrale of Exmnptlto,y....or Id _
bccc,llhol,,o the Worker,Cmopcn0
woa pmvls ons of nae Labor Ode,you must
Q 0om
limhwllh su
Comply will, cs a,h p......iondo,pc lit Irdl be deen ed revoked,
z r0( CONS'rRUCHON LENDING AGENCY
1 hereby affirm that there in a construction leading amne)for the P'rlumunce
:z of the work for which this permit is issued(Sec.3(N7.Civ.CJ -
Cl. Q Under',Name
:D 7 Lmd,,'s Address
f..I O 1 cerlif,that l have read Illi,atTlicud,m and x,Eric that the'eb oi,Intonnation is
Gu �r e ,mc..I agrcc u.amply with Ill city aed county nn0ouoces told sfinaw
e ln(chains
C C.) o buildingnnatruc,ion.and loreby..Ill .precratile,of this c111 to enter up,m
the air srincromned property t"lir inspection purlxncs.
F 6. Ove)agree um save,indemnify and keep harms.•the City of Cupcnino against
liabilitiesjudgment,,costs and eapcmu which may in any any ttcme,gains,nail
V L City in consequence of the granting ufthts permit. '� ♦1/• ,
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONJ'OINT Issued by: �� Date �_A L —VV
SOURCE REGULATIONS.
signamm of nppE,mmta•omn,c,or - Data Re-roofs
HAZARDOUS MATEWAIS DISCLOSURE
Will the applicar,otfront buildingoc'u"nta,enrhaalicros,araol'o,aeael Type of Roof
n.adefinedby,he Cupctino Munic;pe' nJc,Charter 0.12.and,hc H,allh mW SufMy
Cole,section 25532m)?0 Ye` All roofs shall be inspected prior to any roofing material being installed,
will the applicant orfuture building occupant use equipment ordevices whlch If a roof is installed without first obtaining an inspection, 1 agree to remove
cmDi,,,ict?Nous oar conmminunu s fieri cJ by the llny Ana,\ir Quality Mnnagcmenl
car, all new materials for inspection. Applicant understands and will comply with
❑na r all non-point source regulations.
n I have even the 1wr.:rol ns maternalk uJodh Comanv m,aer Chapter.9s of ILc
Culdireia IIeanh&Solely Code.Sec' s 5505,25533 and 25536,1 old...mWdet,
dint,building doe am anL, ,lo, nty mnmrnihility'it nooll the
rupial n(Ibe m, I vi he Inc,prior h,issuance of a C,nitineme of
Occupancy` Signature of Applicant Date
i
r tholfirtal.,c.Vl All roof coverings to be Class "B" or better
OFFICE