00090069 (2) CITY OF CUPERTINO
ntnlAWG.DIVISIONpERNIIT-.''. CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO. ..
OWNIiR'S NAb11i. 0737 S - •t 'x ' APPLICAI[ONSNffAYf. .
PHON&. - - SANITARY NO. C Sl ,
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'❑a Z ARCHIrECTIENGINEER, 'I' BUILDING PERMIT INFOal
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BLDG ELECT PLUMB MECH
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F D 2 LICENSED CONTRACTOR'S DLCLAIdAFION' .lob Description
o z as 11 ,by 11 I that I licensed d 1 iW : 1 Cl,aplu,9(umI to g ,. a
r will s I sola) rD nl n Iv r:: c,we ny�yl ., `,
�'i �11c1. 1 - Lie
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wa F RE—FIPE/WATER HEATER,
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ARCHITLCI S DCCLA OV' -
O� l t nde'slaldny pl xshall be used as D:hl cru' Ic
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p`p Ile f f + _
H ZFQo OWNER BULDER DECLARATION
IhallC 1611' PIf 0 Contractor',
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fell greally, d P .. n'Code Any,,,,, rcounty
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1Sr. p uconsent, ❑ I Iinh p' ya:cmro'
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priern,itravC,ahoI s tile al,plicantf h pernat tofile a signed.t: n:' l _
a 3� that 1' dp tt to pr n 0th C nw t L' H (CI ll 9, -
En l encne with Se,t on 7000r or Dl�u 3„fate Bua ne. , nr,knn..coder -' ^Sq. Ft: Floor Area - - ° Valuation'
la Ran he is uscal,auh -1 d the bmis tot the alleged excia,ption Any violation -
nf5 90il Sby yPPI' too-nP nt,tjete rivappl' I Ipaoul,
,if ifnp,re than rise h areddd ,S500). t,l AP.NNumber - - - Occupar -
❑1,a, ,anrnf the frilailly,VI my employee with wage,us their..],wnipea.ation,.will do the k and thu-stracture is ant included or offered fur sale(Sec,7044, -
Bu d P f:. :C I Th C l I I L- d I pply l uI `r red Inspections
ow '-
f property Who h 'Id. ',prove:the I' d who d b work li tvcll'
othrough or ,,n c uja yee. P- Wed That star in"o6"neah,arc not intended
ffered lot Bare.u;however,the budding or improvamea is sold within one year or ' 2012, -UNDERFC00 R_PLUMB I NGr.
completion,the uner-builder will have the harden al Proving Inns he did not build or -
. , w,,c,vlbrpinIFenecale). 301 — ROUGH, FILUMBING
❑I Ila p ply ad :i lye IaT g d r a, d tramr.to ' .:502 — FINAL" ,�'LUMBING ENERGY...:.
eIct the project(See 7044 Business id Pte
c s t n.s Cale)The Contractors _a
� .tticen,a Law dors,flat apply to an owner or penparly who bailda of impmvc,(hereon, 507 - F I MAL PLUMBING
and who clmuaas for such prujecw.wah a conbacen:(c)licensed pursueat to the •- a - - -
Connector,License Llw.
' ❑l am excmpl under Sec. B m P C tar this reason
Owaer .Date -
WORKER'S COMPENSATION DECLARATION' - +
I hereh ffmn order recall f
yv Ya p rJurytne+f the ft]lox ng dells-n aux:
_ y
❑ 1 have-mad w111 provided
a Cby Sere of Cons3700 of m Lard for Worker',the R. r - -
Compensation, a, surksad for by Sermons X1 of We Labor Code, for the - _
perfnnnunw of the work for which this permit is ued. ,
❑1leave d vell trainnia W art',Coloper,aflondFar,- no, IhyS t a
37001 oI he Label Code Far be pscalannon,c of Lee work for vshr,lithe poncia i, - + t
i"ned. Workers f :i Insurance �Pol 9ptbe'are:
Careerlr PalyNo 7 0/D �Y + -
CF.RFIFICATION OF IXEMPnON FROM WORKERS . '5,,'.,
'COMPENSATION INSUK NCI: ..
7
` UI' uon nacd l➢I be eonplead'fdel rail le fon ne h,ndlad Anila: ' _, ,
I already fland in lie Perio arre, if the k Nor which thisPcurn'.': Nood.I _I ' .• a .
shall not cmplo)any person in any manner a a'to beat me subject to the Worker
Compensation Laws of C;dif inj Date s - a N91 ICE IOAPPI ICANI If,after k' g this Ceddleate of Exceniption,you should
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beconte subject the Workers Coupersation Provisions elfinLabor Cd you mune
.ford wuh coapt}with suchprovisions orlh pool(sWll be deconed invoked. -
F'V� CONS FRUCTION LENDING AGENCY-
> aid kf
II rby R hatthm t 'I' dib agency for the pcdnrna se
� which his p tet-, wcd(S c 3097 Cie.C.) '
Leader,Normo
.7z Lenl Ad ..
V Q 1 avrj I have tenant,application and loi.Ind[lucrative r non n
w E"I cor t 16 t ply 'th II city I county d.t t ming - -
- 0 V rob II I'r sanearea,und herch):mht Iresem:i ves Rh iety In enter upon ' -
} W the aturvc-ractioned property f , l
Pm 'p4 )agree to d fY and keep harrouss(lie City(if Cupertino glint
Vi labilitics,judgments,case d which inanyayact
rto a ga nal.aid
V Z City in couse,ruitofit in g.utingof this prat.
.APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT issued by: r'
SOURCE REGULATIONS ssUey: -Date
°sis I fAppllcunUC"nimctdr 'Data Re R'e-roofs - - -
., HAZAIi DOUS''MATI RIALS DISCLOSURE
'Wn the applicant ature tw'1rg ec,aparl,teare handle n-e l'.anneenal `Type of Roof , .
as d l red by Wa Corpolino M n 'pal Code Chapter 9 12 1 1 t1 I health and Safety
Cal Seaton El V 25532(x)' I a.
All roofs shall be inspected prior,to any roofing material being installed.,'
Will dir.pphea.Iarl.rrabuilding occap„m n.,a cgxlpmemordavluev whlah If;a roof is installed without first obtaining an,inspection, I agree to remove
unit haeaMoa,air eon.i mimnn a,aerated by the Bay Alan Air Quality Managemani
Di,pWt4 .{ all new materials for.inspection..Applicant understands and will comply with
❑Yea i
all non-point source regulations.
I have,read the homrdeus materials requirements under Chapter 595,d the
Califto as Health,Y S .ty C A S f .25505 25533 a d 25534 1 a d that
'I th Idtg ' th t tdat't' y p blpi ffythe
t f e ,.y re unready ich......t b met p' r lois_, [' Cenil wle nr
Occu ac I - -
Signature dApplicant,'- ” ,' Date .
owner a.th izeda,sna,. Data, All roof coverings to be Class "B"br better ` _