00110050 CITY OF OFCUIVISIO NO PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
J
OWNER'S NAME: AI'PhI A'l) 'S ,
. PHONE _ ` ,ANI'I'ARY N ' 3 CA O,
�aa YO ARCHI'I IiCTIIiNGINI:IiR: `a— — RU1LDINOPER1,1I'1INFO
s w C BLDG ELECT' PLUMB MECH
y�6U 1—I CI I� f_1
bb LIa hill Ili GONr,sed aTOR'S..ill RATR)N Job Description
z O Q I herehy illi'n mat 1 nm licenced under provisions sal ChnPner 9laonvnancing .
0=t0 win Stenon 7000)of Dici,am dnfthc Businm,and Profosimn Calaandery licence
6 Y f� ie in full force and lXs s Liecaa cls.,o Commonsut ADA BATH REMODEL
m') D:nu c
"a 3 u iia ARClll'I'I:Cl'S DECLARATION
CS N'� I understand ary plan.mall be read as public nal
cava$
'd Q O Licensed Pent esional /
1C OWNEWBIIILUER DIi(he Cia ION
ascan
W= hmohy.(Bari ar nu:unapt 11 an mu lconiam, o I.iAny c Law lin the
C4 following reason.(S.air l ]ondr Business end Pndc,sionx Civic Any city our fumy
�E v omen doyairc,a pennh sea con,weL sine nnprora deml repair any,waurc
ad ra.3 m prior I I I. rcy [lieapplicant f such Perm t fl sagreal tat merit
that he is licensed p . tt [tic prol oftlicContractor's Low Ckpter.9Sq. Fl. Floor Area Valuation
Int g 11 SsTn]IXXII oI D'v'w't 11the Busmca dl f:mnuri
e ,Ce)
or than hu enyn function,oris the bast,liar the alleged cxcntpuon.Any violation
of SeeJon 7031.5 by any applicant four a Permit mhjcm,the applicant In a civil penally
Of ant ones mato foe hundred dollars(graph). APN Number Occupancy T pe
0 I,as owner of he pmpeny,or my employee,with wages rs their sale compeowls o.
will do the work,and me structure I,non uncurled or olrcred for,we ISee.7M4.
Bo,am,%sad Pull e„am,Cour:'I he Cma moo,,Lmcm,e In.doe,not apply alas `) � ” quired Inspections
owner of property Who builds or improves thereon,and who docs such mark himself
or through his own employees,provided that such improvements are not intended or
olremn for sale.IL nowt,.er,the building or inmroocn¢m is sold within one year of 304 — ROUGH ELECTRICAL
n.plefion,the owneob old,,war has,the harden of pro ing nail he did mil hold or
t;� or 501 — FINAL ELECTRICAL ENERGY
ptuva purptncn
01.asins nerofthe pmpeny,mil escwa.eyconlmetingwith licensed communa In 505 — FINAL ELECTRICAL
aTlmet the pmContractor's
jcct(See 7014,Bn,iness:rod Profession,Cauke)The Contctor's
Liocmc Law dtc,not apply to an owner rel prolwnr who braids our improve,thereon,
mJ who carman,nn'salt aujo,",will, a,onu'unor') Veen,ed pursu:vat et the
Cn no'c n"Lieen.w Law'
01 an exempt under Sec. ,B Yv P C tour this reason
Owner Dam
Wo RK17 'S(COMPENSATION DECLARA'T'ION
1 hereby allium under penally of perjury one of the hallowing dedamtion,:
0 1 have and will maintain a Certificate of Consent it,mmimure for Worker',
Conpcnsalion, ;is provided for by Section 9]1X) of the Labor Code, for the
perlonammc of the work for which nhiw Irermit i,I,,.,d.
01 hast,mW will maintain Warker's Compensation Insurance,as myuime by Section
371X1 of the Labor Code,an the petfmmance of the work for which this permit is
sued.My Worker',Compensation Insurance carrier and Policy number arc:
Cunicr, Policy No.:
CER'T'IFICATION OP EXEMYI'ION FROM WORKERS' '
COMPENSATION INSURANCE
[This o,airn need nut he um.ptract If me permit i,liar one hundred douse,
SHOP)ser las.( ,
I cenify that in the romaimace of the work for which this permit is issued.I
shall not employ any peat,.in any manner ma as or bcarne sobject ria the Worker:
Compensation Laws of California.Dam
Applicant
NO'1'ICE'm APPLICANT:If.adv making tills Ccnificam of limmption,you should `
Q pbecome sunjecl ,,the Worker's Compensation provision,of the Lahr Cale.you must
forthwith comply with such Provi,iom or this penin shall he deemed rivaN.
F04 CONS'1'R UCI'ION LEN01 NG AGENCY
a I herehy atlirm mm turn,'"o e,)s .0 Linn lending ngeney for the pnt'ormnnce
if the work for which this foerant I,issued(Sec.3097.Co.C.)
0. Q Lcial e's Name
7 7 Lankr`,o Address
V O I renity mat I have Octal naw aPphcaaon at,late don Om ahove ark onnall i,
fY
col 1 agree to comply with all city and county ordinances and state law,relating
U to tradding cnmtmetion,and hereby announce representatives of this city to enter upon
} W the ubocorncntloned pari tar inspection purposes.
rFn Coo (We)agree ,, ,all l y and keep harmless the City of Cupertino against
Vi he' hhie..ludgmmn...cols and expemu,which tiny in any way carom against said
t..) City in mm,apmnce sal he gmndng of mi,permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WfnI ALL NON-POINT Issued
SOURCE REGULATIONS.
Sigmnmeofnppftcanvcnmmnor Date Re-roofs
IIA%ARDOIIS MAI'BRIAI.S DISCLOSURE
Will the applicant or future Wilding occupant rare or handle hvnrcmus nmmdal Type of Roof
as dafned by the Comedian Municipal Craft.Chapter 9.12,and the Health and Safely
Cade.Section 25592m)I
OYef ON" All roofs shall be inspected prior to any roofing material being installed.
WillmeappIi,anI None bwlhogornmmna,ecyoipmcattmecyieeswhich If a roof is installed without first obtaining an inspection, I agree to remove
emit harardnm air caomorma rib as defined by the Bay Arca Air Quality Management
District?. all new materials for inspection. Applicant understands and will comply with
°10Nt' all non—regulations.
Wilding
does net Iurudow mm a tent.that
it I%a .....e,xiChaPlero Oil
0l the
Culilbrnin Health,rcede let
Ctvlc.Seasons 259119,25533 still 25534.C understand to 95 i rule
if the haildi t doe,not currently have a must
be thin al i,req ssuance o lay m notify the
Ocupam of the rcyninanems which mull M urn Prior m issuance nfa Cmihcum of
°CopaoCy Signature of Applicant Date
Ownnnraumorimolagent Dam All roof coverings to be Class "B"or better
OFFICE