00110051 CITY OF CUPERTINO
BUILDING DIVISION - PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRrGS: PI:RMII NVj01 10051,
101.23 N WOLFE
OWNLB,s NAME: APPLICATIpNffj)AIYLO�0
JACOBS. GROUP 1 // l1
• PHONE: SANITARY NO. CoNfROLNO.
C ce C ANCIII rECLIENGINEI R: BUILDING PERMIT INFO
BLDG ELF:C1PLUMB MECII
`G.ad
5�Z LlcervseD colvllencroes In:cl.nenn°h' Job Description
horcby ullirm that I inn liecnead water provisions of Chuptcr9(eomnsneing
F„_' war Secular 7N)Hpol D,,i,i,,a 3,d the[last ed Coa,annint, e,nw, DEMO EXISTING MALL SPACE
Y— is in hill force and effect.
d e �U Licv w Chis L¢.p
3 LL F Mule+ Contractor
ARCHITECT'S DECLARATION
t °5I undnsmnA my plana shall be u.wd xn public records
r-
i o'0 Liven sIt,ror aa,+Ian
OWNER-BUILDERraptfr oECLAR/t'1'ION
LL R v. 1 hereby. Sce,that I um,Hu,iol linin the ContI....I Cod Lice, Law for the
t•(�M which
ng renaun. ural t 7031,l..inch and Rulaeeimte Cute:Any salty m'county
E z e which rryussu n permit requires
e construct,uhcr, for
such perm,t no repair any semen
pin t imat 1 'Ihapplicantt hpemiu ik ,L (Chapter
'hat he licensed p rw n d I nn Illi c Business
I ors Carr9 Sy. FI. Floor Area
Icon l 6 with Sect 1gg1) The Division1 of the H nez ldi fA ane Gde) $�� �r/J
nr Ilial he is 3Ie b to y applicant
and Ilia bun fur the subjects
the ep Bacot o Any vinlmion
of Section than vanyapplicantforapennil vuMeas the applicammucivil penally
,+rne.I I+hare man ave nnmbm,muam lssp). APN Number Occupancy Type
O 1,as owner ofine parody,only emPIOYcen wish wages as their sole compensation.
will do the work,and the structure ie not immrded or ot'fered far sale(Sec.7(44,
Business anti I)n)lessons Gde:'The Contractor'.Licenx Law does not apply in an Required Inspections
r of property Who huild,or improves thereon.and who does such work himmlf NO ASSIGNED INSPECTIONS
or
or ldx own employees,pr oicad thin weh hnpa,carents ore not i al a Wd nr
offered for a dc.If,have,the Will i,or impmvemcnt i.,slid within one year of
nn lFlaliull,the nwnerhuild,will have the burden of proving that he did not build or
r for Parole o1'axle.),
r of Ibe Pmpcny,inn c.clusively.....training with littnced vontr wton m
mnurunwi
Cohe prix ea(Sol.7144,Business and Pnnfessions Ctde:)'The Contractor s
Livens Law does not alp,m ant owner al progeny who builds or Inmroves thereon,
and who Contracts Iur such putocs with a cmteenar(s) licensed purennot In the
v�n/t(/i.war'Ip 1.ic sec au. . Alley,PsC fill this rowan,
OP• " -W)N”: )AIITNSKI'B T41l(lI NVr
I M1eteby alliin,unser gnulty nil jury one of the following Jecl:wlion,:
❑ I have and will maintain it CeniGcan of Consent to self-insure for Work,,
Componsution, sax pnrvlAcJ for by So,, 1 97011 0l' the Lubar Code, for the
performance of the work lot nbich this permit is issued.
❑1 have and will actual Worker'v Cnmlwnsalinn Imurunce,as reyuind by Section
Pip of the IaM,r Cade,fur the perforesare of the work for which this permit i,
sue..My Worker's C Insurance carrier ane Policy number arc:
Carrier: Policy Nn:
CI?RI'IPICAOON OP E%EMI'I'ION FROM WORKERS'
COMPENSATION INSURANCE
(This section neN not he varancon if the permit is for one hundred dollar
pit 00)nr leas)
1 certify that in the peeotawne of Inc work for which this .it is iemed.I
shall noI empty any pemon in any manner or as In become subject to the Worked'
Cmnprnmlion laws of California.Date
Applicunl
NOJ ICH 10 APPLICANT".II:uhcr Irking Ihie Cenircun of Encmptiun,you should
b einne,abject n,the Wofkde Cmnpcmatinn provisions of the Leben Cede,You nus,
Q O funhwith comply with Such pnwlsions or Ihls permit shall be deemed revoked.
fz_^ Z) CONS"1"RUCTION LENDING AGENCY
a , 1 hereby alrnn Ihut then:ix a vv+n,naclinn lending agency Ibr it,perf arranm
W 'Ifthe work for which this pemnit is mated(Sec.3097,Ci,C.)
0. ❑ Leader,Name
z Isn.cr's Address
V Q 1 cerllty Ihln I have read Ihie applinnion and,a e Ih:n the above inlivmation is
I.. E... correct.I agree..+comply with all lily and county oudirnws and six law,relating
Q U to building construction,and hereby amhonte representatives of this city to anter upon
} W the:hove.rural aped pnleny fir In,orchil parpne,.
r y
(We)ugme to save,indemnify and keep hatless the City of C.,n,n,,ag.frut
Vz Iixbilllhw,'ndgtncnra nrtla and celmn,Cs whnh nay in any way seems..gains,nail
C) z Cityi c e dtbc .n 6 ilhtn noir. 11
AP I NI RST U A UWI. MPLYWITFIALI NONP INT Issued by: Dat
d
F
I GD r l _r
nYl to at yp,,,o lcammetar to Re-roofs
UA%ARDODS MATIi ItIAIS UISCLUSURIi
win the applicant nr luwre building occupam Blare or handle har not mamriul Type of Roof
derncd I,v the Caped.....Munldpal Cado.Chapter 9.12,an.Ise Health and safety
C dc,Scctiun 2553291+
°Ya• 0 N All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use tyuipmrnl or devices which If a roof is installed without first obtaining an inspection, I agree to remove
• Gini,hwau'dnux Dir caul; InunOas denied by the ltny Area Ai r Quality M nnngetncnt
District all new materials for inspection. Applicant understands and will comply with
°Yea 13No all non-point source regulations.
I have mad tire hazablous maedak rc,lairearea s under Chapter 6.95 of the
California Hoahh ik Safely Codc.Section,25505,25533 and 25534,I understand that
ifthebuilt' gdoe,ad on., has nmunt.thin it in mY rcpemsibility n,nahty ilia
recreant n bi an I, hint a set be met prior u,is, Of a knireac of
Oe a
f Signature of Applicant Date
t intaborid.
, ,car I'` y Dale All roof coverings to be Class "B" or better
OFFICE