01030121 (2) CITY OF CUPERTINO .'
BUILDtNr,1..DIVISION ;PERMIT ' - CONTRACTOR=INFORMATION:
BUILDING ADIlRE55: PERMIMNO. '
I A4 Ell 113B RD LLEV HEATING 8 C OLING 01030121 '
OWNER'S NAME: APPLICATION SUB DATE
4` T:Fl S'L 03/21%2001' "
PHONE. _ - ', � ` SANITARY NO. CONTROL NO.
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❑z Z ARCHIrECTIENGINEER: - - BUILDING PERM]I'INFO
I.00 •n - _ BLDG ELECT' PLUMB MECH
Z y u 'LICENSED CONTRACTOR S DECLARATION ' - Job Description
1 hereby affirson h I I all,I'carnall that,plus hilow of Coupled 9(coanm b -
FZ ed with S 1 7000) fU' 3 ftheBu e ' dP essounCod unit ny l'
�.s. a, ua in�r�Ichsy,erra d`B �(®. JO� L x O FURNACE REGLRCEMENT '
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Date .�__3/ /J/ _ ,ComCLA
3 u t„ — AKCTiITFCT'S DECLAR
; 1 d , I any ].,is ha llh Jri p hl' d ♦ '
0100 Lic dP f nl
°i 6 i OWNER BUIL DER DPCI ARAH"N
sland
ty
u7 C'�ra3F •«: cin'gbwy saffirm
ecmon7W0)d'f Div. 7ahe
Connector's
I .anLicense[,car f nh It
firivsin, (Section 70315eB .nes dCode A y ,Y Z which requires permit :, , II ?ro ,de IM1 p' tiny.t re,
pn , I I th pu It partial I1signed ,I statement
s licensedpursuant tthe parvisdans iftheContractors License Law(Chapter 9
f: :m Code) Seq
.+Ft-p`•F!,I.OOD AreaIT
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or Nu,he Is onampuharridan ad the basis for the unaged c,,dr,I m.Any trillion _
of Section 7031.5 by any applicant for a cannot subjects the applicant m a civil penally late
of not most roan Byehaddred dollars f$5u0). - ;'APN Number - Occupancy Tfpe -
El 1,monvaram'tlmpmparny,or my,employees with wages as their sola compensation,
will do the work,add It,structuren t,' t d ffered I,,,
Sala(Sec 9044, 440
- -
Bus'. d Francs Code:The c tr t r:Li :e L does ant apply ill an ` ' " Required Inspections
o -
w rot ppany WI b 'Id. p 'Bhrc 1 I h khila If .• y"
or through his own employees.y : provided d don 1 ip s t'intended .:204 — UNDERFLOORS FRAME
offered for sale If,however,he building improvement is sold w thin one year of - .+
.B
rmnpmtimn,the awner-bplmerwillhave[tic burden humoring mmbedid net build or
imefppf ) - -,3QJ1 ROUGH, F'PLUMBINGBING "
❑1 : r-h n e ty l.- ly r g 'mf tw t t - `„ 3�03 ROUGH MECHANICAL
construct the project(Sec.7044 Business drfss+ons CodahIn Contnaturs 304 ROUGH ELECTRICAL.. .'
lcdanse 1.w docs not apply to an owner f p ny who builds improves Bacterin - -
and who arousal,for snehrproans with a...Issue o firrow,il fa r..anLh+doe 505. —.-FINAL 'ELECTRICAL
Contractors License Lie. I ' .
❑Iait,aiamp,order Sae. B&P Car this npa,ca I. x" 507 — FINAL PLUMBING
Ovow, Dole 508'•— 'FINRL MECHANICAL"
WORKERS COMPFNSAL ION.Or CLARATION -
514 - FINAL PUBLIC WORKS
Thereby notion and,,founty of p'-kry one 11 I'llbefiffliwon,dedrardtims,
❑ I have and will maintain a cenifcu,e of Coaseni m self-inure-for Worker's
Co p :at m provided for by Sled 4700 of.the Lubor Code for ,he s s
performance f the work'lier whichwork' Ibis Pamir is issued,' ,
°I have addwll anciatia.Work,,.0 parentrad Insouniou,,a:required byS Yin r, ' -
3700 of the Lubor Code,for the perfor ova ti the Bork f hich this pen i t is+ -
sued.My Worker's Compensation Insurance carrierand Policy`mmther are; - ,- - •+'
Is
CarrNb:
' Policy N
CERTIFICATION OF EXEMPTION FROM WORKERS'. .
COMPENSATLONINSURANCE
(This section need not be complmed if,he permit is brute hundred forms k` '
($100)or loss.)
1 ecrify that in thelprournmeed of tic work for which this pernat is issued,I v -
par not employ any person in any manner soils to become subject,o the Workers _ *
-Compens itrim Laws of Cul for,ll Daceu e
Applicant
NOI'ICB TO APPLICANT:If,af,c,,,W:i.,,his Ccrdflcam of Exemption,you should -
Oheeome eublett,o the Worker's Compensmian provis ons of the Lubor Cuda,you met
fonhwith comply with vueh pmvisians or this penny shall be JearneJ revoked.
Z
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CONSTRUCTION LENDING AGENCY t y
E't > I hereby uffrn thattherea swat nn Icnd,g,ye y'f -lac prrfnrmu uc k '
rip the work for wh ch this
s per n r s ass ed(Sec.3097,Cr,.C.) `
W A Lender's Name' -
d Address
t..) 1 adir,for,I have leadtIn ppl' , d state ilia,thbove itmormiation'.
-
cos t 1 agand,nervously with all city and county-concord, d deedless raisi ng -
'� r„J to bolding consticarod,and hereby authorize representatives of this city planer upon
ati til
the move-norationedproperty f .pe, purposes
C. -
FLr Are)agrivto save,incantatory rico ha ' C C,Pug iZ nh Il ad,dread. t Jexpensesalahmay innwayncme against ad
-
sad,
C,7 z City' q,encs
it th bcmci,g of tln p m t
r Ns
AP NT 'DER�I'AN9�AND WILLCOMPLY WITH ALL NON801NT I,
db ( Y..7 r• Date
Sign I AppbaaCm/Contipir7or • Data Re-roofs '
- HAZARDOUS MAI ERIAIS DISCLOSURE
Will,hanpplicue or future bulldingoccupun,store or hula]],hleardommuslc,iul ,Type Of Roof'
as defined by the Cameroon Municipal Crate,Chapter 9.12,and the HerJth and Safety - " r -
CudvSec,]on25532(3)7 .y c -
DY, - °N f' All roofs shall be inspected prior tdany roofing material being installed. `
Will(he appladearalutione building(lerupart use opopt I ver which If a'roof is instilled.without first obtaining an inspection, I agree'to remove -
emtl d dominant,rcnadefnad by the Bary Are,A li 5
1, Manag nt
District? all new materials for inspection. Applicant understands'and,will comply with
°Yc °N" all non-point'source regulations.
1 filed rend the h d ;nationals redia rcmr ch,under Chapter 6.95 df hie - j -
Calhorti,Hoath,&Safety Code,Sections 2550525533 odd 25534`l understand(hilt ..
it iha building dues roc cunranly hove ateman,In.,h is any ra,ponaihility luridly the • - - 1`
eauyant'If the ray 'rcandes which nest ha'net pr nr m... of a Cenificme of ` +
'Signature of Applicant Date:
4 r or amhori ed.,cm Dae - All roof coverings to be Class"B" or better'
v. "OFFICE ,