00100214 CITYBUIoFNcuPERTNNo PERMIT CONTRACTOR INFORMATION:
RU ILII INC,AODRESS: PFRMIT NO.
OWNHRB 1.:G� WOLFE RD — APPLICATION SUIT DATE
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SAN[IARI`NO. CONTROL NO,
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RUILUINO I'IiRMI'1'INPO
O ANCIII'1'ECT/I;NGINIiER: BLE X: ELECb PLUMP MECH
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LICENSED
h CONTRACTORS DE1Job Description
I ncrcny action that I am licensed under provisions of Chapter
9 faomnxncia
F�CW with Sectton9NXbolD,caiun 3oftht lfuaittcxaand Pmhv,iunr Calc,unJ tnY lican
< -c is in full force and theca.
,
n e -a
go: Class Lie.r REPLACED WATER HEATER
9m- Dam Comracwr
a.rn ARC]111 n CI"S DECLARAON
f=a 0 g 1 makrodmi my pinna shah be used as public reemk
to
trail p 00 Licensed lholca'ionIt
OWNER
-BUILDER DECLARATION
w e, 1 hereby affirm that I am cxanpt fmm the Comitant License Law fur the
C 5 oldros log maann.l Scotian 70.31.5.Huai , nJ Pmtcc ns Calc:Any city orcomuy
-'x O which quina a permit to command.alter,aupras'e,dantdisn,or repair any,tmemre
fork) in its issuance robot requires the applicant for such Permit o file asignolstatement
that it,t,doer—l'amaam to'he pro"11111111 or the Contmnm'sl ovale law fOmpmr 9 Sq. Ft. Floor Area Valuation
or that he I%a with t bamboos
the
basis
o the
alleged
e s and ion,Any vi Gdel -
or htaa he 7 e¢mpt an,amt and ane oras.for abj alleged exemption.Any violation
of Sacton e to s rev any dred d ll for a pumrn sttbjtas rot npprieam m to dyd pxnahy
of rota anon loam bye lnnnamd nauaL lssan, APN Number Occupancy ype
❑I,as owner of the prnpery,or my entplayeex wpm wages as their sole compensation.
1111 d„the work,and the artmatm Ia on;mended;It otfcrcd for.sale(Sec.9044.
Business and Professions Code the Co emaurs License Lawdues not apply ,,an equired Inspections
r of propeny Who builds or improves thereon,and who dues such work himself
rvtlrznaght ow
bin enllldynidsuro
ro,pnwea mat ch impcement,am or,intended
attend for s a.1f,howevm,the nwldlng or namoc mmtn r
is within one year er 502 — FINAL PLUMBING ENERGY
annplatumirmcowmer'bui'd'r all loocthe marmot proving that hedid not build m 506 -- GAS TEST
improve- purnasa a
❑Las owneronhe property,amencwzivdyeammedingwian fitenttdcommcmnro 507 — FINAL PLUMBING
construct the project iSec.7(94,Business and Processions Code:)The Cameroon's
License Law mss not apply loan awns of nal emy aha hvildc or Improves aheram.
rend w'hn License I'La such projects with a nmtmmnrs)licensed pursuant the
's
❑I ntu uctnpnmJcr Sac. .11 M P C far his maven � �G/�/\✓/�+
Owner Dam
WORKER'S C'OMVENSA[ON DECIARATION J
I M1enhy affirm under Ixwlry of perjury one rel the following Jn1amtions: J/
I I have wu1 will inninwin a Certilicre of Consent to null insure for Worker's Q l
'n,creation, as prm'ided for by Section 3710 of the Ialan code. lin the
performance of the work for which this permit is issued.
O 1 have and will maintain Worker's Congwneatiun Romance.as required by Sinton
3700 of the 1aM1m Com.for the perfum eme of the work for which this p.Oil is
.cued.My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATION OF H%LMPTbN FROM WORKERS'
COMI'ENSA'1'ION INSURANCE
fro is section need not be completed if the permit is for one hundred dollars
Slab or loos.) -
I racily tM1rot in the performance of the work lin which this Pemba is issued.1
shall not annple,any perann in any manner so as to Iscariot,subject In the Workers'
Coupe sals o Laws III Cnlilinniu.Dam
Applicant
Not ICE TO APPLICAN9':If,after nmking this COmmitte of F.c.ptian,you should
z ntaainc-subject to aha Woke",Crn. oo,an Ipre c ns of the Luber Ctdc. on mist
Q O forthwithcomply wire such mo isiann or this pv.It,start be decided rcvakad.t
CONS'I'RUCI'ION LENDING AGENCY
1 hereby mhrtn thin ahem Is u curtwmmainn lendlu,agency lin the perfctoounce
of the work for which this comit is issued(Sec.3097,Cis.C.)
6. (� 1,coder'.,Name
Z Lender's Add,a,,
C.7 I certify that I have mad this application and state thattheabave information is
[r c:reel.I tg le In comply 11111 all may and comity atJ arriers'cud same Iowa relating
Q t.>
or building communion.and bomb)authorize momsemalives+dtbia city to emerauor
the aMrvcman irncd pmpsny for inspcmion Impose.
F C (We)agmc o,xavq nJcioniry and ksnp harmless the Clty of Cngwnino against
N liabilities.judgments.coats and expenses which may In any way accrue against said
C.) 7 City in cause....Oc of the gm ring of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE;RLGULAOONS. y'
Signature oLkppllcam/Commmor nee Re-roofs
I IALAItI IOUS MAI ER1ALS DISCLOSURE
Will the appficatn sir Wrom building occupant.corm.•or handle na..dium,nrtarid Type of Roof
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Cum.Sonin 125532(n)?
❑Yea 0No All roofs shall be inspected prior to any roofing material being installed.
Will the applieanent'bottom bnildingaacnpantase egnipowntordevices which If a roof is installed without first obtaining an inspection, I agree to remove
amit ha.ardous air con.motion,ac termed by robe Bay Area Air Quality Management
Worms all new materials for inspection. Applicant understands and will comply with
°Yes 0 N all non-point source regulations.
1 hate read the hmnNaus materiaB quirememc under Chapter 695 of the
California Health k Safety C do Sermon.;255115.25533 and 25534.1 understand that
f abs huilding do—nna couremly hove a tenant,than is is Iny eve nnibilo,to notity he
occupant III the requlrenmm.s wmhof
which must re et prior ,issuance a Ceniliane of
Omnpanay.
Signature of Applicant Date
Owner orammmucil.,On Date All roof coverings to be Class "B"or better
OFFICE