01030038 (2) -CITY OF CUPERTINO
suil.owcmvlstov PERMIT
CONTRACTOR INFORMATTON `�,
BUILDING ADDRESS(' '' _ � - .., PERMIT NO.,
20345 CLIFDEN WAYSCHAUMANN. PLLIMBIN 'AND
OWNER'S NAME: Y' A r _ - - _) APPLICATION SUB DATE
RON HEYMANLRUP.ELWODD I?. 03 10A�PL71L7[1
PHONE: • ' - _ ! SANITARY NO. CONTROLNO.
(408) 986-9044
w Z 'ARCHITECTIF.NGINEER: - - - BE
PCRMIll INFO
Fe 0❑0 ( - 1� .BLDG 'CECT PL.UM�B• CCH
H
Z z N LICENSED CONTRACTOR 5 DECLARATION m [ Job D05C1'Iptlon s
OZ—p Ihereby 7(f)(hnnikllart l' B d p fChpt m e -
r�r3�et wth Sudan 9aNp ofD lot tb'd ndP I . t .Cod•and myl e
fallf, .
w t.tcn I e a REMOVE ' 8. REPLgCE FURNACE; 45;:000 BTU,
a°d Dat.'d c orae .ADD 2 'GUM ALC Iahl I ,
Rcunral snhcl
FtSy„g I a t I YPI hllb Ip of - d: _ •.
y60� License,]P f :' I. . rr OWNER-BUILDER DFR DhCI ARAl10N ti'
1 1 sY d that-]10 nco thecoronation',L 1 for the •�j _
„ roll y (S f "c,u 5 13 m ro f Code'.e Y 'tY ante
� Dowhich requires permit a t It p demolish, p Y't tuc
u�i m Pr t t '. q ' pr gl tf hafile a 6 tat m "
o, roti f do tt top In Contractors L Law(Chapter 9 'S' Ft FloorArea :` - Valuation
m, 6 thS t ...d., :l d) q'
or mat he 7 exempt a f oro end th' m.r d for he ullobed empho L Any omit
n 4
of Social,
.aeo1156yv hundred dollars
apenn't. bj cle meappl -mmacivil penelty' '
of net .are dtnn t.,e n l d I titin.Issap. APN•Number Occupancy Typto <' -
❑Lar owner erne property,dr my employees with wages as men stile compensation.
will d he work,told he t t I'mardi offered to IS,,9044
Business aid Professions Code The C t t :License Law Joe,art aTI,or an - r 2693700fg:� tied Inspections `
mr of pfoperty Whol ids m imp...s thereon uad wh I m such work bmself -
mmuglu ni,own employed..provided that such improvements arc not intended or
' -offered for sale.If.M1owover,the buildins ur-itnpnw amid is sold within one year of
a,mpI,Iid. meownd.-hmIderwmlame tire burden nfprevmsmn,hedid not build 204 — UNDERFLOOR. FRAME
impose for purpose f salej,
❑1 we ftnP pny 'ly ntfyw th license(]conditions to
301 — ROUGH PLUMBING
the p i ct Ise 7044 Hostile I Profit:: .CW ) rhec i a t 303 — ROUGH. MECHAN I CAL.
Licensed aw does not apply to an owner of property,who builds or'improves thereon.
and who eentmets for nmh'p leas with a onrzarnorfs)licensed pursuant m the _. 'a,, - 304' — ROUGH, ELECTRICAL I CAI_ -
f 'Contractor's License Law.
❑I am emmpt under Sic. °_; - .H k P C,fon,this reason .. .505 - FINAL-ELECTRICAL
owner' Date ' - 507YF,INAL PLUMBING'. "
'• WORKERS COMPENSATION DECI.ARATION -
508 - FINAL MECHANICAL''.
In rorty,drnn a–flatly fpi v nn ,followingp 1 f 51+4:'—,,.FINAL PUBLIC' WORKS
❑ I have and will anceporm a ceirldidde or consent ,, self mad, to,worker's e .
-- Cempensaion„m provided for by Stettin 37od of the Labor Cede, for the -
performame of the work for which this permit is issued.
a
❑I hate and will maintain Worker's Compensation resonance,m rrquiad by See 2 a
3700 of the Labor Code for the orn f the m,for Hdi this scanit's
soentire and Poly card, a'
s
CERTIFICA OT EXEMPTION FROM WORKERS
OMfit PLNSATIONJNSURANCL
If section need not be wmpleted If the permit is far ane hundred dollars
IS 100)or less) I If, - -
1 unify that in Ore perfomonau di tl irk for whi h this pendi,is Lcsuril,1
'hall bt dna,ltly any personal in a.,mon ter sn us to becom•.uldea to the Workers
'
(76amear,mind L v, f C l'f .Date s I -
_ 'Applicant
NOHCHTOAPPI.ICANT If udcrnrtk gth-C tr..e of L6dmptot.you should '
5 btcone suhjecua theta k Compeu t 'Incisions of the Labor CON yml ta ° +
Emhavth comply wlh .Or potshots,or the per r't shut hedecmed revoked. ' -
z
,a CONS ISUCTION OLLNDINC ACFM1CV -j '1 heady, ri m that them Iconsumerism J'ng agent)forthe pedti ranee - - - a
L' afro
,,,it rich lh p ni ssw.d(Sec 3097,Civ.C) ta
l7W,tQ hcl
Name
t7 z Le Address
U p - _5 K,
I certify mad lyant dattlttl binformationt
• ko '� to t l g t pin with ll tY 1 county of and ti,am llfng: '
Q V tan Il gunstna an and henAy euro ' p'.auotbe of tbls_c'ty roman Iron _ '
ry the h onedp , Of inspectionp l ..
C6 (We) 6 t d ifY dme,h dl .Ibe Cay fCpen'noagtn:t
V] Ilnl It j dg t: r. pe es 1 ch Y n any Y tdn'n t -tiJ
U .zi .City 1 "'Goer¢of d gr tit n f b peri t. 2
AP Cf TUINDERSNS J WILL, PLY WITH ALL ON-P INT Issued by: ` Date
iga root Applmadcof ct ow, r Re/�,sha
t t - -
HAZARDOUS MATERIALS DISCLOSURE ' µ
Will the appneatnon future building andnpam.tard m l5andle havntJtid.material, Iy ^. .
a as defined by me Cupertino Municipal Code,Chapin 9.12,and the Health andShfmy.
Code.Section
25532(6)° I.- q No -- ,El .
Albe inspected prior to any'roofing material being installed.worn ppliu t r t nwldi s p tr"6 eq,pmentnratette. roti Iftall@d.without first obtaining an inspection, I.agree to remove*h' d cmt t: dddnW b)tM1 Bay Arte A'r Quarry Mnnag tit
Di t ave. ' ,r El No, - All new aterials for inspection, Applicant understands and will comply with
all non-point'source regulations. is
I hmse mail the h nd cn :regorc t. u 1 C pt r 6.95 1[lie - - - ,
Call II Id &Safety C
af tyC I Se 5511 25513 d11114 t 1 nJ r nJltrt �6 p r- ' +
fifth btld'ng dor,pa tlyh to tlht i y r'pershltyto noff e - - - '
_ tofthemmot I,wh' teethe mpnurms m
ieofu teat f J-
tp' ) , . Q t ';0. Sigita[ure of Applicant Date, r. n
,t mer:.t stns - ate All roof coverings to be Class"B" orbetter
:.OFFICE . , '