NO PERMIT NUMBER \.1 e).1.'111.aUR:rcu
CITY OF CUPERTINO
BUILDING DIVISION WOCRERMIT CONTRACTOR INFORMATION: 032/02/2001
BUILDINGADDRIZ S PIiRMI'r NO.
' 'iSon
OWNER'S NA IR: APPLICATION SUB DATE:
l
111ION17: SANITARY NO, CON'IROIL NO,
n i?o ARCBnliC7IGINEER: 19,.F.J;T FY-1bLL�l.� BUILDING PERnlll'INFO
0 pp BLDG ELECT' PLUMB MECu
FEW CI GI I_I I-1
Z LICId S1iD CON'rRACI OR'S DIiCLARstfoN Job Description '
O'4E I hereby affirm that I nor licensed under provision..of Chapter 9(commencing
v,rw withSminn 7fxNll of D;vision3ol the Business and Nn Z..�nn.C'.I`.n n,y sash..
I—_F� m fan force mx ecf J 3 N/RI
S a,w Q Licen.m Claw __ Lic.p
Data�_.g`��0� Cnntracu,r
w •ARRRCIII I ECT'S DLCI,ARCA 10M1'
so Ithdcr,and my Plan,Shull be used aspurl lc rmoMs
CLQ%
ec6 0 LittmmJ Pndessional $_N200
a C w OWNER-BUILDER DECLARATION
1 hereby alien that I am exempt fano the Contractor's Liceme law for the
r Z v following rearm.Stall 1711.315.Brame,uad 1'mfem eh,Code:An,shy nr exmmy
FFa xli pemil l x her ho c,dranolikIrorveloi,an,nhr aura J r• r f
wn3� priest t do .......h ppL^ It hl sill II 6 dol:nr ant 3i_(.i4:J0].7.IJGl
that he 1 dpursuant l the p -o -01 l c t m's Liven.,d 1 •(Chapter9 Sq. Ft. Floor Area Valuation
(commencing wire Section 81IXB of Divinlnn 3 of the femme,and Prnfev,mo Cole) rtf1
or that he is exempt therefrom and the basis for the alleged exemption.Any violation K)4 F%f.X '1 FIFXJTRICAI_
of Section 7031.5 by any applicant for a permit subjeon the applicant to a civil penalty
of net more than five hundred dollars($51X)) APN Number-;(%)]. — FTJ:IJfIE. E:L..E•CTRmWcLtnFiffYpe
�La,owner afire pn,pany,or llhy emPlnyee,wllh wagon an tela lest...... hxa1ialt, I:.qtr. .-.. '- F-FITRITMI
will Jo be work,and 0e structure h nal intended or Offered lot,ale(Sec.7040.
Business and Prafesiom Code:'ITc Contractors Llceme Lew does not apply u'an Required Inspections
mincrol project Wilds ovprovcs ,and subsodews mch west hunself
or through his Own.mpinyccs,provided)that suchmpnncmns arc not;mended or
erJ 1 .If, t building(it improwmantis sold within one Yx, of
cooloction,theowderdmider willb
j
the burden fp ing tl'tl did tohu llor
'nptwf I I....dot -Icl
❑1 t I je Pr(See 7 h e ux siv ly t r i will licensed contractors h, j
constrict the project face 71oa Ba c, ❑papery
f s il% )Th C th t
License Law Jews not apply m an owner(itwith
a contiy who builte or improves mertno
and who commas fix such projects with u umwcmrts)licensed purmum to the y /
Contr:mum'.I.iacndLaw. ✓
E]I mu cxrn,pl order
r Sec. .11&1'C for lhln Baum
Owner.Date
WORKER'S C0MPENSAf1ON DECLARATION
1 hereby affirm under penalty of perjury one of the idlowing declaration,:
❑ 1 have and will io,itedo u Croilicule of Cnnmmn ,, 'elfma"me t'or Worker's
Compcnsmion, as provided for by Stank 371b of had I.mW, Cole, for the
perfnmunce of the wed.Lim which his permit v,i,ao&
Fare and will maintain Worker:Compenution Insurance,u%requited by Section
3709 of the Ulster Code,for the pmfordenee Of the work for which this permit is
i,sncd.fly Worker,Cons :do n l I mature carrier aanndd1 1ppolilic_1yp�n ib"er arh. '
Carric[�CER IItlG �'F F.\EMpolicI'NION I NUh1 W(IRKIiRs'
COMPENSATION INSURANCE
fihl,,.vine need oat be ever lined if the permit is for mm hmulred dollars
(Ellxp
c,Id".)
I certify that In(lie Itidlon dance Of the work fur which this permh is issued.1
shall nm elnploy any person in any manner m as it)become subject U)We Workers'
Compen,almn lax,of Calib^m;n.Date
Applicant
NfnICE TO APPLICANT:If,are,making this Ccnircatc of Exemption,you should
buvvmm subject to the Wader's Compensation provisions of the Labor Code,yon mn,t
Q O rallwi,culnply ,,It via,Itnvlsian,err Thi, *^nit,holt be deemed revoked.
FCONS1RUCr1GN LENDING AGENCY
7 I hereby alien that them is a construction lending agency for the performance
fire week in,,which this .it,is;...ed(Sec.3097.Civ.C.)
L A Lender's Name
,7. Z Ismer,Address -
V O I renily that I have mail hit,:lPplinniun and state dwt the alas-inhmnrnion i,
k. E.: a.rre.t.1 agnc m.....ply with all cihy and county ordanamr od stmt laws rchling
0 V to building construction.and hereby amhurim mprcuntmives of Ibis city u)enter urym
}
di uMncnxntinnd grai for ImPecdon purpose,.
ryt
t m OXc)agree save.indemnify and keep ,p handle the City of Curl against
1F-1 W Irdeh ics,yWgnirnu,cults and expense,which may in any way neem.against.said r
aCity in eoh,c,ocnce of the g1'mll inb of this p.nuh.
APPLICAN'1' tND•iSTANDS AND WILL COMPLY WII'If ALL NON-POINT' Issued by: Date 2- �-- �
C.Sft1 �1I:RP 1 0 S. Vol Y'
Slsnulur f pvhcanvctormc or s'1 Darer Re-roofs
fDV,ARDOUS NIA ERIAI ti DISCLOSURE
Will Im applicant nr future bonding isee pen sane or hmNlc that manus,n:etcnal Type of Roof
as denied by the COPenlno Mi ;pal Code,Chapter,9.12.and the Ilcallb and No fay ,
Cade.Section 25532(o)'s
ElYes JNo All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hazardous air c^nlamima -defined by the Buy Arco Air Quality'Mmer,cmmn
. Distdn7 all new materials for inspection. Applicant understands and will comply with
El ye, "^ all nun-point source regulations.
1 have read the boardous materials requiremenu under Chapter 695 of the
Carfornia health&Safety Cdr Sections 25505,25533 and 25534.1 undemmnd thin
if the building di not currently have a tenant,that it is my rcspmsibiliay to notify the
OIdquat of the requires is which must W mel Priet m ismance of a Cenitieme^f
ccupa"
Occupancy .Z �OI Signature of Applicant
Date
r wnernm m ri'ua :-- All root coverings to be Class "B" or better
agent ani
OFFICE