01020098 (2) CITY OF CUPERTINO
BUILDING DIVISIONpERNIIT CONTRACTOR INFORMATION: -
BUILDING ADDRESS: , - , PERMIT NO.'
VENUE 01020098
OWNER'S NAME: APPLICATION SUB DATE .
02/20/2001,
PHONE: - - SANITARY NO. CONTROL NO,
.f
❑p O ARCHITECrl1iNGINEER'. - - ti + BUILDING PERMIT INFO '
LuL F r - BLDG ELECT PLUMB'
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LICENSED D CONTRACTORS DECLARATION e 9(o nmc g ' Job Descripiion ' • -
0 44,d will, f 9000) I D 30 he Boston,,and Pr f Code and ntyl
d is i III force ad•ffct.
� �a LawmwCmss . DEMOLITION 'OF'.STRUCTURE
°xl 3 N Data Connector
ARCHITECT'S DECLARATION -
a, I undem°nd my plan,slmll b,uwd o,public recordsce -
}
pOLicensed Professional
._PukSEGJ7 Y^�Fe6',�G❑y ' OWNER'-BUILDER UEC1•0
N
I[reach, fthat Iam the Contractor',
ontrt L ' r or th•e
following (Section S Business sJ P f .i Code Any city o
which requires l u1031l t p J I'1 pi-any structure
�o� ' t f I ' titapplicant Ip smnen
that :licensed t th p cal . fntit c I Lice...Lt (Chapter
Sq. Ft.' ,Floor Area • -
Va4
luation
(comwith en]mi)ofT Bu: J P f Code)
otitexempt therefrom and
he liand the basis for(he allegederemitical.Ay violation 10a 000
ofSoeot9BIl5byany
appicamf teubjeets the ,labralna cvipearly APNNumbeanamore than nvehundred do]has($500),
-
_
,r
Occupancy Type •.
I,leownend l he pmpery,army employees with wages as that,sale compensation. - .
will do the k,and he lourtme's n t attended ,,m1cred f :at N .7044, -
BtII Professions cod TI Coadmctor'.s Ciaers,Law does not apply to a, - .. Required Inspections'.
f p p ly WhoId. r l pow e t
r :the ,and who doe inch work himself
�rw through Ili.owls etuploycee,provided Imo such improvements u,, t Intended in NO ASS I CNED INSPECTIONS
uttered fur sale.If,however,the building or improvement is sold within one year el - + -
ampiclion,the ownerhoilder will have the burden of proving that he Jia nd(build or
interest,f p 'rywe CL 1 )' - - „ 4� -
°1 t ol tire Trapani, i la contracting with licensed commewool
man m the pn jenl(S,.'1044,Easiness 1 Pufe..ons Code'J Th Contract.,',
ncto2s
Cleanse Luiv Jocs na upp1Y IC an owner of pmpenY.whn hnlA'or improves Ihc,unn, -
and who.eone
rtos rot such pr fwl
acts with a cnn
chub)lken.ed pursuant to the t -
Contract'),,License haw. - . ..
01 t ler ec B&'PCT this
Ow ��Dmc' c2�sa/oI
' S COMPFN SATIOND CLA AFION VVl
I throrb,affrn r I mda,Pduallyor,,jory I a mfilhefollidstan,at t'
C
❑ Ihave d I,ill aminali a
el fConsent nit lf W
pe kr'pe : d provided l itof bby
Section n 1900 f the labor C I f dh '
pet t[tie work forwitich thi,perialki,,aca.
❑Ihave atd will na nitin WlawFs C01pearalima lmraace ax required hyS clan -
3901 of the Lnhnr Code,far the performance oLdic work for which this permit is .. t
sued.My Worker's Compensation Insurance carrier and Policy number ate: -
Carrier- Policy No
CERTIFICATION OF EXEMPTION FROM WORKERS' ,
C'OMPENSAT'ION INSURANCE
(This seedier need not be conllemJ If Ih°permit Is fur one madmd dollars
($100)on less.) +
I e,aIIy tlmt is the performance of the work for wha,h this permit is issued:1 .. s, -
shall not employ toy parson is any insurersore m hourne libjm lu the Work°rs'
Congrrnsmion Laws of Ceiifnntia.Dam
Applicant
NOTICE POAPPLICANP IL rafternialsol,ath Cedifiewe ofFacradirtt You vhold
becomeu n"'
"a Worker'C Mon p :' t tire L.Inr Cole sot uasl .T ^
O s fnnhvi I h comply w In provisions or dh p ,d slwll be doontalrbroker . . 1, • - ...
I..
F .�-I thaNSTRUCTIONLENDING AGENCY -
• ai > I by fIn m that tit ,ne d n 097,corma,C agency for the performanm -
at Lea kf II'ch lit permit is':noel(See.309],C'v.C.)
Q Lender x Name
U Q Lnd .AJJmss
1 carrif,that ICa 'dth's.,pl,,:I,i i mad mtc hill th1ave ammunition is - ,r
W [r
Correct I Reto ly with'II cityand county ordinances laid state laws at `
' O C.7 to laildia,construction,and hereby annual presentafves of the bit,to cam r,an
[T] the,boll-mendunal PmpcnY for impecllnn purposes.
y Qn (We)agreeIoM jr,armif,a I kar,n' I. the CilsofCti,mfimo against
Un liabilities,jtuc,andI: n:and iblperre,which aY at any way ir came a,aaara slid
V City In a(Hisequence ofll granting oftbIserion. ,
APPLICANTUNDERSTAND`ANDWIL`COMPLY WITH ALINON-POINT �+••�zz l
SOURCE REGULATIONS. t,�_, -o_ . O�•_'Q� Issl dby:'. DatC
Signature in ApprconlleennewiTRe-roofs '
HAZARDOUS MATERIALS DISCLOSURE -Will the ,dcamr,Entire hrldIng p' r,a ri,or handle lim,ladorearmanal 'type of Roof
it,defined by the CopenN c pal Cal° Chapter 9,12.a 1 the 11 hh and safety
d ' - -
Code Section 25532(°) + - `• • _
°Yo` No All roofs shall be inspected prior to any roofing material being installed'. is
Will(heappuetal ar Future ha0diugoeeu,md and aqu,il ,,de,i,,,which If a roof is installed without first obtaining an inspection, I agree to remove
milk I : r C damned by the Bay Area A' Q .I it Management
,
Dia' f .• all new materials for inspection.'.Appllcant,understands and will comply.with'
DY N all non point,source regulations.
I have read the larroomp,ardenA, airdareass muter Chapter 695 of the, ,
Cal'forn a Health&Safety Code,Sections 25505 25533 and 25534.1 undelnland that '{;, •' ,
ifthe building dues not currently have it denanl,[fiat it is my responsibility to notify dire ,
- ,spent of the re placruents which muss he met pilar to issuance of a Ceddleate of
��L Signature of Applicant - •Date • ,
'i"� r, — 'AII-roof coverings to be Class R" or better.,
MICE