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CITY OF CUPERTINO
CONTRACTOR INFORMATION:
BUILDING DIVISION PERMIT
BUILDING ADI)k Eli
10090 N IA1nI FF RD SLAI T —P -17P
PERMIT NO.
0104 095
OWNER'S NAME
cl-1prRITNE-i ;:Tmatmcmi 177F
11 -PR
APPLICA'I'[ON SUB DXFH
04/1 /2001
PHONE.
SANITARY NO. - CON ROL NO.
AlcCHITECIYENGINEER:
BUILDING PIiRMI'I INFO
ItLDG ELECT PLUM MECH
_ IJP f�
LICCNSITO CONTRACTORS DECLARATION
Job Description
I Berens mTnn mar I an, licensed under provisions of Chapter 4 (commencing
wire Section 11XXI)it Division 3 of lire Buainesn and Pore,ion, Code, and my license
i`' 'n toll force and eBFec.
i«nauB aa_ [�7 Lie.n�{ //__ �.
DEMO.
ctntmeantl`��. _
u
ARCh S DI!CLARAT
ll the u oa
1 undcmanJ my plana shall be nscJ as public ncnrds
Licemed Professional
UWNIR-BUILDER DECLARATION
1 hereby affirm that 1 an exempt fmaithe Cordocc n'. License Lw for the
following re,,a, (So,, 17031.5, liuviness and l'ndc.,.ianc C,de: Any cosy or cnun,y
which requires a permit to construct, altet, improve. demolish, or repair any swcture
print to IN'iamance.aka ,tiir.. Ihn epplkma Inoouch Punic la file i,i,ncd w.maam
Sq. Ft. Floor Area
Valuation
that he is licensed personal cc) the pecvi.amnsonhecontrmmusLicense Law (ChaNer')
(n,..... aming with Seeellnn 7 0(p of Div' n for dm 1lusince, and Professions Code)
or that bis exempt churchman and the basis rut the alleged exemption. Any violation
e
of Section 911)1.5 by any np,Iwwa tura permit suhiect the a,plicanl In a civil malty
APN Number
OccupancyType
,if raw mare than Fee ImndmJnonan($5(10).
❑I,asownerofihepmpeny,ormyemployeeswdmwagesastheirsolecomp nvdon,
S i620 0"4'
Req td Inspections
will Jo the work, and the Mratrov is n it inle led or ofmcd or safe (sec. 96,14,
Business and Pmfcisions Conic The Contractor's License law does not apply to an
of property Who solids or in,pro es Ihrvon, and who cines such work himself
a, through his own employees provided than such improvement, are not intended or
NO ASSIGNED INSPECTIONS
offered lot .ale B; however. the bidding or in,prnvmfear is ,old whmd one scut ur
completion, me owner -homer will have the Women of proving tbt he did not build or
mprove for pntptae ifame).
❑1.a of the poa err.n acluxivcly eo..I ..ling with licnna,l corlecoor; to
,
anrvucl me project (sec. 7044. Business and Prelusion. axle:) The Contractors
^
License Use does cot apply to on awnor of pe,a ry who miler or iotnrooes therd....
and who contracts far such poject with a eontmemKs) licensed pursuant to the
Cl
❑I am c,,U under Sec. . H A Y C for this reason
pt undo Se
I a. exempt
Owner Dae
WORKER'S CIIMPENSA' I' ION ,IiiCLA101']ON
I hereby churn under penalty of pcijery one of If, fallowing deckircaiors
❑ 1 have and will maintain a C'crideate or Conscnf In .dgina,rc for Woolen's
C
Cmopenwuun. as provided for by Section 3701 of the Latin Code, for the
Performance of the work ler which this permit Is Issued.
A���I have and rill maintain Worker's Compensation Insurance, as required by Sctliun
%)
_
of the Labor Calc, for the lerfnrmane, of the work for which this permit is
isa c& Aly Worker's CC/mOO�n�l���e��n��x99mion In.rumove carrier and Pat her ;ec'
Caric':/'IWORKERS
cIiey NON
/
IF'ICATIIT�J i)F EX PYM:22'o�—_
C00.1I'IiNSAT1f1N INSURANCE
IUB% section need not the completed if the permit is for one hundred dollars
($ lap or Icrs.)
I cenify Iba at the performance of the work lot which this p .it is i ... rd. 1
.hall not employ any peon in any former len it% m hectare subjecty, the Workers
Co:Ilp"'alitn Lows of Cafifomin. Care
Applicant
NOF ICE TO APPLIC.ANO. ,L ,f,er oinking the, Certifieae of Exennpfon you should
become aubjecun the Workers Compen.aion previsions of the 1 -nim, Cale you must
fonhwiih comply with such provicions or this pannit shall he deemed revoked.
CONgTRUCI ION LENDING AGENCY
I hereby fifrm mat mere is a enma amoon lending agency for roe perhanante
o1'the work or which moa permit is issued (Sec, 36X91. CivC.)
LendcrN Fmne
'
IAnder's Add....
I emdfy thm I awe read moa om,ftcmio t and late mat the nhove inmonnaon I,
correct. Iagree to comply with all city and county ordinances and sate laws relating
to suildingnis, ceo,cau erchy authurue«Presentative. ofthk city coenuru,sn
the ahveaam non ed pm ty 6r ins an purpoay.
(we gre to save indene' :mJ kms arndcs.. the City of Cupv no agcon"
nsiliths, Jgn -uta, co i ant apenseI which t ,ay in any way ac In again,, said
/
City 'Inc req nee of d s Bing on his Perna.
-�
Y
APPLE A NDBRST. SAND WILLC MPLY WIT I ON -POINT
Issued b Date
y'
St :F LNUONS
/Re -roofs
HAZARDOUS MAT Ti AUS DISCLOSU E
Will meupplicaam mamhuiming .,,nsce,toretrhandleho ,aa anterial
Type of Roof
as defined by the Cupertino Municipal C e. Chapter 9.12, and me Health and Sulety
Cala Section 25532(a):'
'
❑Yes 0 N
All roofs shall be inspected prior to any rooting material being installed.
Will the applicant (it future building occupant use equipment or devices wInch
Ifit roof is installed without first obtaining an inspection, I agree to remove
emil haaamom oh eomnminnot, ar dcfm l by me Bay Alcan Ar Quality Management
m
Diaatx
all new materials for inspection. Applicant understands and will comply with
O Yes El No
all non -point source regulations.
111, a It, me immolt„. In:nedal, m,mm ue.va ,..,mer CLI par h.95 ot he
Calilhmi Iemt BS. my Cc , 25505. 25533 and 2553. I undersand chat
ch Jing ocsnot v Ply huv am nl,mutit'dnry n.po sib lily to nndlyth.
Ins
cup. Iof enquire which must met prior it) iiu se of a Cenifac lc
(kca ,
Signature of Applicant Date
— -acd - — " —
� . All roof coverings to be Class "B" or better
t r Bram-, uga Date'
• V OFFICE