00090038 (2) CITY OF,CUPERTINO '
BUILDING DIVISION PERMIT'" CONTRACTOR INFORMATION:
BUILDING ADDRESS - - - - PERM❑'NO.
OWNER'S NA*"30 - - APPLICATION SUB DATE,
YJOINED
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PHONE: BET " SANITARY NO. CONTROL.NO.
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ARCH]'fliOf/ENGINIpiR:• - (650) 298 849A
BUILDING PERMIT INFO-
Ck BLDG ELECT PLUMB MECH
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to 6
2 H " m LICENSED CONTRAC'TOR'S DECLARATION • "Job Description r
O -e I hereby am that I am licemed under provisions of Chapter 9(commencing
m with Svilimi 7000)of D son 3 of the Basine:.and Profession.,Cade,and my I cense ,
ay is to fall force end cif t. t
�K 6 Lia Class
Lic.of ;, r
Dae Contractor " , • '
F.3 0 n ARCHI YEC7T'S DECLARATION
�'=°a I:mdetaond'In I shall mm records ,WATER HEATER
s r� r.panssa w
u7.6 O o Licensed.l'rnfe"amal'
o OWNER-BUILDER DECLARATION "
e I has by affirm thus I.,it eupl Hard the Contractor'.License Law fnr the
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following reason.(Sconod 7031.5,Ii ;' 1 Prof.. Code Any sly coamy ,
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which aconites ot penor to commort, h tprove,thadolish,Or MPUIF any structure
n 3= prior to its issuance,also requires the applicant for such pcnn Go file a signed statement
that he is licensed puna:mttotheprovidun.,ollh,CommemrsLicense Law(cnalner9 Sq. Ft. Flocr'Area Valuation
(esmmencing with Seelian 7000)of Dlvisim i 3 of the Businms and Pnd'enidm Code) +
or that he In exempt thendmor:nul the basin our the alleged r,rinption.Any violation • '
of Section 7031.5 by any applicant fora permit subjects the applicant to a civil penaly ,
of not mora than five handred dollars(ssuol. AP.N Number Occupan�cyType
OI owner fahpmperryor myeiplyets%,nil wages ni B I ' pen: fon f ' bIILLIt�ljA1
will do the A and the strumec is nit intended or offered te.ale ISce.70,14!' '
Baines sJc'O
nitPrfe. omComCom a . L se La dntapplyt an '75 i,8Q1.7•,6&uiredInspections
mcaner of prow ny Who builds or improves thereon and who does such work himself * s ¢�n�[Ir
through his own employees.provided,bad sreh lnprrovet man,am not ImmndN or p
o1I'ered for sale.If,however,the building or improvement is sold within one year at - -
unpresoo^.mcux'nerhall,.), juhaaemebamenurprn.mgmatnedid mmbuild. 502. — FINAL PLUMBING ENERGY
t p pugxaw -
❑I.ii.owne,d me propony.car e.cm.ivel,tooddedng with hircnxed cnntrhnasm 50P., — GAS TEST
unact the project see.70,W.Hisincss and Profession,CNntra
Code,)The Coctor's
Lmicense Law dries not apply to an owner of propeny who builds or improses thereon, ;50T - - FINAL PLUMBING
and who ennrxcD for such projects with it contraclund lirenscd.porsuanl to the
Coleman's license Law. t I - „
❑I am exempt utWer Sec. - - ,B&I'C for this reason -
Owner = Date
WORKER S COMPENSN ION DECLARATION" + '
I e
I hereby affiren underpenalty ofperjury ma of the bellowing Jcl tin s
Cl I have aid vvill divid a Cernficale of Consent to selt-indra,for Workers
-
Cottpcover provided far by Seed 370(1 tthe Lithor Code. f - the
N,firommor, fthelook fidushich this peon t J.
❑I have and will unwound kc Claro,consallon Insurance.as required by S ci mt
3700 oftil L'bar Cobe,far the p rf rural I the It f h this permit is
I issued MY Workke/s C n,emai on Ins6rance carrier and Policy n n la arm: O O
st Carrier:- PnlicY Nn.: s `
CERTII'ICATION OE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE - +
(This union.,,it not be a:mpleteA if the pconil is for one handred dollars p ,
(S l tgpor lce,,1 a •• v; +
1 rectify that""he perfonnnnce of the work far which this permit is issued,1
shall not employ any permn in any manner Lar as In hecnme subject m the Walken.'
C d'a'aio I Laws of cadhomr.Dam - - - -
Applicant .
NOTICE TO APPLICANT:IL afmr making this Certificate of Esentption,your should ,
INemne sabj.,to the W'urkee,Comitem Corm provision of the LuMrc Cade,you must
O 0
forthwith emnply with such provisions,or this pctmit shall he deemed revoked. -
r
F es.
CONSTRUCT is a hJN LENDING AGENCY '
W4 > 'thereat which that thereiss csued(Sic. lending agency for The perfonnanre
W nrthe work far which this permit is issued I5aa.3097,Cie O)'. - -
0. Q Ld 's Nun .• .-
O Z Leader's
m
Address .• .• - '
U O
I I agree
thalhme read this.,ay a,]iommnruladahatthe,Mwe,law,, hili is 1
W. �y rnrmn.I agree tr comply with nIl airy and rnnnly nnlinnnccn and sum lows rablling
O C.7 rah Id gconstriction, ndleaby nNu > repmNandifives ofth':cityI enter upon ,
} W the nobove-drindrand pmNny for inspection purposes. -
•�. pis (We)ilgiso mime,Indemnify snit keep handles,the C,lofCpen agenest
n•I h ihlt j 1lt aIs, e granting dpcnses al y' 'nY Y gil:nl said
CiJV ZS ry -color Ith I r l - t^I I U
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINT Issued Date
SOURCE REGULATIONS.
Signature our Applicant/Contractor -• arm " Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
W311 the applicant our Throw holding occupant start our handle Tractarians material, 'hype of Roof
_m JefneJ by the Coped in.Municipal Code,Chapter,9.12,unit the ILeahh and Safety s
-Code.Section 25532(:0'f • I I '
11 Yea .°N All roofs shall be inspected prior to any rooting material being,installetl.
Will the applicant or future building rccupant use equipments devices which If a roof is installed without first;obtaining an inspection, I agree to remove
ill h l"a"Im"air ci morin rituals"dofincd by Tho Ba,Area Air Quality Manngrtnem - -
.,met, all new materials for inspection. Applicant understands and will comply with
0 ye' ON. - all non-point source regulations.
I have cul the haaurdous nrneiale mqulrmncnd under Chapter 6.95 ul'the
California Health&SUI'cty Cadc.Sections 25505:25533und 25534,.1 undersand that
il'tholm dingdues nos radially have a mount,that it is my mponsibilirym nosily the -
er.,em of the requirements which must Ire amt prior to issuance of a Cedificam of
Occapare'., Signature of Applicant ,Date
'(-
Dwmicmdatnnriudagent' Date - - All roof coverings to be Class "B" or better
ti OFFICE