01040072 (2) CITY of CUPERTINo CONTRACTOR INFORMATION. i
BUILDING DIVISION PERMIT +
BUILDINGADDRESS: ,'..f - + PERMIT NO,•-
OWNER'S NAMIi^ - _ APPLICATIONSUBDATE
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` 'PHONIi: ' _ Sl 10W I'WE 500 AIRPORT SANITARY NO.
136I
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K Z e\RCIII rLC'rIENGINEER Y BUILDING PERMfI'INFO
O O_ _ • BLDG ELhCr PLUMB MECH
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11--7 y " LICENSED Il CONTRACTOR S DECLARATION l o IOtt Description
Z 1do.?YaftrnthI I' tl 1 p [Choplcr9lttnnm et ng y,4 al with Seetorce mid of D' nal o(the 11 dP f:.ons Code,and nyl - o n
sin full farce slid cR cl t _
�a .License ClassI b'
Date - Cmtmcler REPLACE, 50,_GAL rGR&(WATER HEATER _
uI 3 uso ARCHITECT'S DECLARATIONto
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�` Oa I'mnderxond mY,bor,boll He used as public records, , . -
�to
X00
Licensed Pf ': nal r " • ..
OWNERRUILDER DECLARAI ION ? , -
I hereby that pt fr n IM1 t C I I' f the
affirm
tJ e5 following res m Scatter 7031.5.11 and Prodc,lican,Code A y 'IYcounty -n '
rSG wl h 4 e"in Inumilic,imarrart,alter,improve,de 1'I or rapstriary.merum c - -
m fr i t I ,,law,th ppl tl hpe,.1,1.file6 dat nt cy -
a thatn licensed p pursuant to[tic provisions ofd Conartiourri,License L (Chapter 9 Sq'' Ft. F1oorArea - °'Val uation -
(commencing with Section 7000)of Dvison 4 of the BusinessdPolesslons Code)- - •r
nr that he is exempt therel'mm and the IN...for the alleged exemption.Any vicl,umn '
of Section 7031.5 by,any applicant for a prount mbjam,the applicant to a civil penally. 1
of not more than five hanamJ denan,(S5Bn7. - - 2;APN'Number :. Occupancy p
D 1,as owner of the property,ar my empinyws with wages os their sOc compenet, -
will do the work,and the structure is nal intended or offered for sale(See.70,FL - - - -
Be s are,sad Prnfesdaax Code:The Contractor's License Law,nox,net apply to i n - - C ed Inspections- ,
r orpropnny Wbo builds or improves Iherwm,and who docs such walk himself - Mw ^ -
rt
through h'. me.,tcs prod ded d I 1 1 t. r handed or "
utteredr . r.Bboweve"nobnldag pr f ' Id m year of 't502'.'—' F`INAL,'PLUMBING. ENERGY� -
in pl 'cn Ibewelc builder will have the burden rprnvi gthathedid nolbulldor , h
mprove For Purpose ofsele.). 50F� — GAS TESTin
LaS nwnernnne� par em, elY ImI s ithl 1 Iclrs lo' 507 .--'.FINAL PLUMBING-
Edconstruct Ili project(So,.7044,-Nr atnc,add Pref of oas C )The Cr andalt •a j
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r Li I d ex nal pplY I-'n owner f, ,Deny who b l I- ,aver thereon c „ • ,.
and who connects for such penpal with a enntractoas)licensed p,rs,naat in,the .. . .
CioneartmisLit,mil-aw I
• DI our expoope under Sec, t B&PCforthis r - -
Ow Dale FINALE=is
_ WORKER'S COMPENSATION DECLARAI ION- 1 {� >'
• Ili Ly affirm 1 P 'ItY fpej ry rth f II bJ lar Y n.a , DEl1 + sat
Dlh d ill ma t ' aCff 'I IC ,,lith elf-name f Workers - la 20 01 't
Compensation,' a, pnmzw mr by Section 3700 of the,Lubec Code for tire _ .+
Performancefib work I'ir twn 'nlh: I :' d. 'BUILDING . . ._. .
plh J dl maintainW k Compensation 1 : e 4 dbyS I n
3700 of,the I abrl Code,f r the performance f the work for which this permit is
awl.My W,rkere Compensruon I re res a anti Pol'y b v -
Is
Giricr: Policy No.: + ..
-.C[RI'll'ICATION OP EXEMPTION PROM WORKERS' .
COMPENSATION INSURANCE
s
Tic section need not be completed If the per n t is far one hundred dollars g: '
ISI INR or less) a ,� -
1 certify that an the performance of the work for which this permit is issued,1
.shall not employ pay person in any munner or as to become subject to the Worker,' I'
Camper..don L,.,of Callfomttr Date
Applicant ••' ..
NOfICETOAPPLICANT:If,olleniwking Otin CenlYcam of Exemption,you nbould - s - „ a
M hj ttwlheW k :C ,east p -ma of the l.nhor CnJe you inuah
0 fth n lh ' comply will, rich P s n fl:ppard shall be decreed revoke) '
F'z CON.TRUCRON ENDING AGENCY
I hereby afri m that dconstruction ding agency for Ilio partesi
E aof the work fnwhorl Ili,permit is issued(Sea 3097,Civ.C,) - -
G,Q Lendeda Name"
„7 Z Lender's Address
I certify that l have reed his application and note lhal Ilio alem,an ,...noun
W F con'ect.I g,,a to comply with all city and county ordinances and state laws rclato, w -
'. QfU
to building valid...earn,and hereby amhoc,o representative,anus city to com,imen
the h eafnned craftily f popro I poses. -
�` f[1rJ, (W)agreeI a 'nonswunifyand k phandles,thCry fCorporal,' bun"
li:b'1'f j 16 i t: d pose h' h may in any way a rnrn,im.t sand
C.1 Z City' nsc ice of the granting of the pcnn't. ' t ' - -
^' APPLICANT UNDERSTANDS AND WILLCOMPLY WITH ALL NON-POINT IsSuedb 'Date
SOURCE REGULATIONS. y - y• r•,
sb t nrAppReanoc,atractnr . Dare , '' Re-roofs . ..
HAZARDOUS MATERIALS DISCLOSURE
IWI thea Basun or future hoildin (store or hurdle h...i,U i pi,ar al'
Pp 6 e,Couple,
- Type of Roof
as defined by the 32(a)1na Municipal Cade,Chupmr 9:12,andihe lie. LnJ 9ufety
' CoJo,Section 255321n)'? - -'' -�
El Yes DNo All roofs shall be inspected prior to any'roofing material being installed.,
Will[tic a ppl future building occupant use in,topper,or taster,older If a roof is,installed without first obtaining an inspection,`I agree'to remove'-
cont tr:rmnr_,a reolmaans a,demes byte,Bay Area Ar Guafty Management
Didmor it all new materials for inspection. Applicant understands and will,comply with
Dy', 0 N all non-point source regulations:
I have add the d : I lk recalopmends tinder Ch pl i 695 of the +
California Health&Salary Cd5tion 255(1.525519and 255341 understandthat I `'r
if thebuilifingelocs not currently have a notion,that it is Toy no,porribifilyI many the
, -
c p t of the mcla rements winch nu t b I p' r e, oft Centfeate of -
Occupancy. " "Signature of Applicant ' } _ Date
a4 t
Owner authorized agent - - Dale-�- - - ^All root coverings to be'Class "B"or better
1 OFFICE '