00070111 (2) CITY OF'CUPERTINO '
BUILDING DIVISION,'•' PERMIT. CONTRACTOR INFORMATION:,
BUILDING ADDRESS: J I - PERMIT NO. r
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OWNER'S NAME: c . . t I - APPLICATION SUB DATE
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ti
ONE - - SANUARYN . C^ 0.
. t ( 10Y30
_ BUILDINGPERMIT INFO' -
Me4Z ARCHITECT/ENGINEERi - " `
7847
p - -
"te r BLDG, ELECT. PLUMB MECH
Q
�Z�dp CENSEDCOYTRACTORSDECLARfION
z8mpZ Job Description
Ihby'ffmlhtl
amine cd d gro,i,iors atCh'pt '9( g _ -
wilhSrf 9(1001 fD nJOfWeB .sand Prorexi .Cade.mdnyli - • °04 ^ -
Y E; is 1.11 f and etfcct. , - - _ - - ,
ek< ue Class e x WATER HEATER
CK!y U Dae ` C t t
3'u,-4 • - ARCHITLCTX DECLARATION
u'Cto
J r 1 andenslandarypl s shall reu. d''pbl Dards I .. FINALED
ae dl
a�
Tf: l
o - 4 _
OWNERBUILDER DECLARATION
'. mLL Ih by ff flan l ptf theC t' I 1 I' to,
- JUN .V(� 5 2001 ' °
C tol ng rcau n (Seel 70315,H d P f ' Code:A y-ly -county ^ • `-
Sn which ruryres n pent to 11 It _ p d tain any.t I '
3
t'its issuarice.rlsolualifliesthrepInch,fsuch P ti fld a"'ieddrucherst r
he,he licensed Pursuant In.p- nn c a t r L Law Che,evir9 Sq. Ft. Floor Area- ,.' Valuation- '
,(co g with5 t 90W) fD : 3 of B dP f ':' '
Code) UILDING
or tat hes exempt Remittent and the b isfrthe alleged essuiption.Any v'olefon
of Section 0031.5 by any applicant Poi'n permit subjects the applicant to it civil penalty
- of not more than fire hundred dollars(3500).:a . APN Number - Occupan q e'
❑I as crofthend he
nycisi y wThwago.o ae Grsole e(Seneat 41,k '
will n thek d Ih t 1 t t I I r R d f I (4 9flgi' -
Bu. d P f s ri d ThC a i . I La d l apply I an �•_ gLll[ed IDSpeCt10I15 l' „
r of propeny a to ids nrlaminae,II r and wh 1 s such and 1i mull'
or through his own empty provided' tl t. 1 ' peart lit Teed it � � � '-
offered far sale lr howrvrr the handl , improveap' n.within one ye r. 502 '— .F I NAL .PLUMBING ENERGY'
completion,the owner builder will have the burden of pros ng that he did not build or
°itnpm�rrr"oup.enr.ale). 5716 —' :GAS TEST
of f the prope,ty,ailnexclusively contracting withl . d ,' : 507 .— FINAL. PLUMBING
o sumer the pr,,1(See 9044.Business nd Pr fe..'ria Crdc.).Tm
ee Contmr's .
License Law does notupply a an owner of propeny who hard,or improves du'ebn, < f - • .
and who contracts for such projects wlth.a commelode) licensed purauant to the _
Cn t t mse '
Ounder
+ f ?
I exempt
pI u derS ❑&PC Por rile ch.m
'Owne Date
WORKER SCODECLARATION
lhecby aH'rlunderp really ifpedaryancfthefollowing
[/Kn lG/• (O/•
7 I hove aid w' ewide'n a Con Securer
Conoco to eob'nmr�,for Worker's _
'e dorm and a t as-prat del mr1hy tt i S t 1700 of thel ann� Cale, for the -
perl6rmence of the work tar xh ch Ili v p iis issued,
❑Iha"td will ail'' W ke :C P f 1 q "dl seenin - +
3901)of the Lebor Code,for the'perfrainanned of the work for which this lams i is
sewed.My W'orker's Compensation'Insurance carrier and Policy ntunher ,orar
Carrier "' ..r., Policy Nn.:. _ t .0 i"._
'CHR'IIFICAfION Of EXEMPTION FROM WORKERS:
r -COMPENSATION INSURANCE +
(This secdounded notno eii
f Dc,rat's for one handed dollars + -
(3100)or In,,.) 3
I reify the,in the pef aroccofth work far h' I d'e,panel isnod,V
shall L cral 1cuser in in,menn,ijid it,m become sal,re't to the Workers
Co per,shion Laws(if Cahfom'a Dale
Applicant
NOIICPTOAPPIICANT if,iflormakingth:Cnfute offourorption,youshorld ° 7^ 1• ". . 't '
bee my subject totheWorker's Fp r p of the Labor Cde you ni,I
0'Q madmeth apply with hp 'sots or tM1 panitehollM1 dremeJ eked
F 4 - CONS,RUCTION LLNDINGAGENCY t ' ,
•
thereby aft m th t Cher :e c n w f le A'ng akc Y f ih perfrr Hance
W
of th k f 'h' h Ih peon,': 'uud(S c 3099,Civ.C)
Leader's share
Lender's Addhe,
I cerlfylhut l bac.it this'ppli 'un entitledthat the abovef t
current.I agto crhplywllh all city anti county ordinances inned state laws 'elt'tg
0 V lobuilding I tction,and hereby al fin erepresema .ive. 17thityt 'rano Lon '
y the alnwe mead o ted P ..6,1,Frann,,vion phipsoj
Fy.C,r (We)agrecte suedindemnity and keep hrrmins the City of Cupertino against % « -
V1 C' He. ludgn e l coves and expenses which may in any y against 'd
City' u
: ryeaceor theg tmgrfth'pe 'r' ' t . py.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTlin
'.SOURCE REGULATIONS , �. - 'n 'Issued by: - - Dale >ir—' V
Signature of AppLcanucnntrartor pate Re-roofs -
HAZARDOUSMATERIALSDISCLOSURE r -
wn me anel eaot r a e building oect pat t stere or handle I' :m :»a1,r d .'Type of Roof
as defned by the Cupertino Muv opal Codr,Chrpmr912 and the Health and Safety,
Cal S f n25532(a)9"
❑yes' No - -'All roofs'shall be inspected prior to any roofing material being installed. ;t
Who- ppl- t future building l t e"et"h "furriers"wmrn If a roof is installed without first obtaining an inspection; I agree to remove -
tth rdousurcom the as dernm by.the Bay ArceA,Quchy Maequan,al 'w"
for
Cl Yea 13 No ,• all new materials for inspection. Applicant understands and'will comply'wilh
,,... alLnon-point source regulations.
- I M1a a dead the hazardous mutual,rcrunchier,ord CI pt 6,95 di W
'
Cal r mHealth&Safety C do Serion.25505 255930 d25511 I rid -.a dal I
iflh b 'Wing docs martial h l n dal It. ty p bltyt nfy the
m o ,
oceupof lherequi ens rwM1ch junior act prorm'i.uanw aa Cenifc roof
.Occup'ncy.
- a _ Signatul Applicant _ Date'
-" Owad,, thod:ed.gem - r Date ' . I_ . All roof,coverings to be Class "B"-.or better
OFFICE ' .h