00080103 (2) CITY OF CUPERTINO.,
uun.nivc DIVISION "+ PERMIT CONTRACTOR INFORMATION: '
BUILDINGM26E . 8 CASS ..PLEIUFFALO' S , FRCICITLESr�IIRVICES0Q�0801�Z
..
7rvEHSNSCANNELL! THOMAS J' ET .AL. •1'411 N ',10TH ST nrr nT1�ffy1 �2�tQt0
ONE: SANITARY NO. _CON'IHOLNO.
(406)287—'0121
7. cc'CHI IECTIENGINEER: .t a BUILDING PERMIT INFO ..
,Poo a , ' BLDG ELECT PWMI3, . I MECH'
I'_Z2LICENSED CONTRACTOR S DECI ARATION' '� - ,lob Description its d
O11 by fl uh t l I censed d p rChapt 9( a B' - •mti I 7000/ fD nh e IP r •)e Y'li -UPGRADE. PANEL
� I fllf d r /�� cl : 1LTSDECLAaI
Sw�� ItndenmWn d 'roll be notice, b, oris , u' /Le� , 5' • s
ammo0 Lac dP f:' nil
OWNER BUIL UFH DI CI ARATION N.
-
1 he eby uflnm the(I nm oscmpt rr a the Connector s Lice'
I.ax fia'the - -
C G fall tib rc'. .(S I 7031.5,B J I"fe':' :Code An, ly count,
$a C wh h 1 p I t n. t ❑ top J I'h P ).....t
- m3m Piot t''. I. 9 'ih FVI- tt M1pr It tl .'g d.lt tit - t -
Inat n r e p t a m p rm c t a t r L e Ln (Chapter 9 Sq. FL F.Ibdr Area : -
':•-r -Valuati
(m g to S 1 ]IM10) f D 3 fm B t d P C 1 Cod) - �
rt that heI pit f Id tr I II Ilgd II .Anyviolation _ �;I • t r -'
oI Section 7031.5 by ) PI I' t t operant object,the apIn t t a civil p _Iry,
til a I n e Io- r n o-w m u,r. 1x500/ A o�S7 '� c9. Q�0 Occup incy Type
> ❑1 '. rnnnen=merry or nvenpmr 'm Gngesaxm . le en nlanaai tit - ..e.
•wind Ih k d In t t of mended or offered 1 le(s 7044,'
Bus d P f Codethe' Contractor's License La d not apply I an r L , ..
w fp pe4)Wh hand,,., p .th d h J , h workh If X304 '— ROUVfI 9tV �K�t.LHI.-
ab brought ': tip y '1 ddtht 1 pn em t IintendedoI,
efmdfor sle If,ho mbIdg pm tis' If h' nernnf 507. •— .FINAL ELECTRICAL• ENERGY
Lomplet ear the owns n Id will hhvetha burden efpnv'ng mit hedJnm huddor _ n
nPmve for purpose of d1e.).. - t - - 505 — tFINRL 'EL.ECTRTCRL•
+. OI ljl p e ty ' xl d) I I g withl 1 Y 'License
et the project(app Ito a Bus ar id d pr wore l 1:)ar Contractors
'
Ldwh Laudocs not apply to.aowner fp pny nnhullo' ri for eslnceon, _ -
!, aid h e tat. [o h projects wi0 c ntmewr(n)I J p m t the -Contractors m License Le - _
Cllmn ese tpl under Set. -- _ H&PCf Ilwrnon
Ow Dole
WORKER'S COMPENSATION DECLARATION
=l hereh) Iffrnutdni penalty of pmluryaneofthe loll ,dcdarafta
L l h ae a td r-
'
11 m mN a Ceri fame A Convert to ve0i'an a fo-Worker's - t
Cat V n a ,.pr 'd d f r by Se i 3700 f the L b Cede, for the -
t Perf nnan e of the w Jk far'which this portrait : ss ed. -
+1311 d will aiia W"k 'C dear f 1 y d by Sa t en s `
VW f0 LAnCod (hep•rlorr a of the work for hthis p ifs
su d M \ k s C ya : C I m "' ul Policy Y mbcr,n e'. / ,Pla
Policy No:
RIFIATIOO .KEMPTION FROM WORKERS t it
COMpENSATION,INSURANCE 1.
This c ern need not hoe ampine I l thep tit is for one hundred dollars r n -
(51110)or frs,.) •b -
I.reality that onPei, of the k t which Ihi pe mit' 6 1 e,
',all t jury any p nyman . t beton sapicot In the Wyk 'x -- - - 'a
Cm p .au n Lows'of C h a.Dore
APpllcare
t NOTICP.TOAPPLICANT If ftrockinga Certificate of Estaft on-you xhm ld
hedane subject to theta k C p : p tfled Labor Code you mist °
-�
forthwith ua nply with such p s c as or pe t t dull he 1 ted revoked.
Ft ,CONSTRUCTION,LENDING AGENCY' ` • s
1 hereby chiral Ib I thereconstruction I...d ng age cy f r the pert amtance
of the work forwheh thisVrn'ts a sad(sec 3lroA,Or.Cl
Lend Nun e V _ _ F -
t.� z Londe?,Addre,
` 1 r
J
UO len'fy tl I l have read the applicationand state that the M f t X f yt
com I I & t pl) th II"city d my endurances J:t I 1 reading _
t..) mb If 6' .t t dh by th p rivs Rh'. tyluenee V a E
the above moor ovcd prdpcny for Inspcci n purposes dr. ,
).1y (W)age restive, 1 fytalker,h I ..Ih,Cay ICP Y '6 tot -
i..iW .liabl ad t: t - d )iury 'Y cmc dyaw od f -
ex Ienh
City t tl gaming Ihi t -
APPLIC UNDB ND. LLCOMPLYWITHALL ON.P ANTI' ISSUOd by a Date
SOURC EGU F 5' t' Y
Sign f ppl n Re-roofs
IIAL OUS MATERIALS DISCI.OSII
w m pplen - I nlrg«wPmtanrenen dl 'L rd :t mdul 'Type ofRoofa I '' -
asdefacdbylM1eCupc na MaroiPd Code Chapter 9 12awde Healln and Surety
Cod Se Ion 25532() r - .
°Ye All Yoofs shall'be Inspected prior to any roofing`matetla] being Installed.
Will pe ppl I r I n la' g v t sn ern p I d ikx whim If a roof is installed without first obtaining an inspection J`agree toiremOVe
one
Balt h'zrdma u'rtnnt n al,uy defied by the Bay Are.Air Quallty Moe darianl .-
Fra t all new materials for inspection.•Applicant-under stands'andwill
comply with
°Y f' '' all non-pointvsource regulations°
p! I h d in,It verJ ,arrieriiiis realtircurna,ander Chapter 695pnt the -
Cilifelain Heall Sof Code Sections 25505 2 533 and25534 d .t and fit., tr v.1' - - -
fifth b Id id -,,,area rea tlyh tel I r is ) p 'pliryl n tly th t, •(;' '
occupant 'I r juareme Ifcb t p' r to "ture'e of a Cen'rate of
oee p'n ..
a.
Signature oftApphcant Date t
ata Dale 1 - All roof coverings to be Class `;B"or better. ' s,