00110010 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT• CONTRACTOR INFORMATION:
` NUILDINC ADDRESS: - PERMIT NO,
WNER's Ng1sJB:709 CULBERTSON DRIVE - APPLICAT1411L,f1 Ma 10 ,
'PHONI?: SANITARY
LEAI_ ' /. NIT
O C ARCHI'IiCT/F.NGINIiIiN: - - BUILDING PERMIT INFO
BLDG I.1.EC*r PLUMB MITCH
LICENSED CONTRACrOR'S'DECLARATION IDI) Description
I hereby affirm that 1 am licensed under mi o of Chapter 9(commencing
Fy with Section 7")of Division 3ofthe Bosinessend l•rnfes,was Ced,and in,license -
q
s in full force and vffi
itU Lieonsc CI !O I,Ic,k'
fa�3 LL Date ���'� rU' /. C,onfeclOr .•
�a� nNCHrrr:TSDECLARAr° ELECTRICAL UPGRADE
g 1 undemund my plan's shall be used us public mmNs
iO O Licemed Professiond + - .
J e OWNER-BUILDER DF 1, RADON - -
u] inI berehy affmr that I ata exempt from the Connector's License Law for the _
f= < following reason Sectio,](131,5,Bminesa and Professions Cod..Any city or county ,
O which requires a permit nn compact,after.improve.demolish,or repair any stme or,
d prior to its issuance,oho msiairmthc.Pplicamforsuch Permit o fit...ign,d malcontent '
the,he in licensed pumnant ,,fire provisions oflhc Contmemrs License Law(Chapter o S' Ft. Floor Area .
(,ommencing with SetIon 700 of Division 3 of the lousiness mod Professions Code) q' .+ Valuation
or dor he is e,emm I ortvfr,.tn and tlm basis for the alleged exemption.Anywioladnn
of Section 7031,5 by any applicant for a p,rait sah ecl,the afepleam loo civil Penalty APN Number - Occupancy pe
°1,m owner of the property,ru mr etas oyem with wages a Ibeif sale a(S a.7044,
` will do the work,and rM1,structure is not intended or oRLaw for sale Isco.]o an
mane..and Pmfc Sias ewe:'I'na,emnwmpra u,emn Law m,ea matt apply to ansquired Inspections -
orr nl'property Who builds or improves thereom and who does such work himself 375J ELS^.J. I i1, '
through his own employee,provided that loch improvements arc not intended or s
oRaed for sale.If,however,the building or improvemenl is sold within one year of ,
completion,the owner-builder will have the burden of moving that he did not build or
mprnvl for pmpnse,lf.,,r.), 304 ROUGH_ E1LECTI,1.CAL
°I.its nsvmeadhe popery,am exclusiealy antraoing with rcens,l counmemrsm 51711 t:T.NAl ELECTRICAL- ET.IERFlY _
Lonstruct the project(ties.7(44,Business and ProessioCode.)The Contractor.
m icense Law does not apply m an owner of property who builds or improves thrown, � .'--s GIS ._ FINAL. ELECTRICRL
com who contracts for such pmject�with a comramis)licensed pursuant to the
Connector's License Law.
°I ton aempt under Sec B&P C for this reason - S
Oviner Halt, - a
.WORKER'S COMPENSATION DECLARATION
` I hereby affirat underPenalty l'PeJ rY one of the following I I tions:
° I h 1 will atainamin a C i t Con,cal no R' -Wvkcr
Compensation, sw Ica f by S I Jf theLabor CvJ for the
merf c fthe � kfwhichuh:me tf,t
.
t' -:.uW
❑I have and will maintain Worker's Com,penuentsin Insurance,as linq by Section y ''
3700 or tit Labor Code,or the ,,rforounce of the k For h h ths permit is v ry^.
ossa MY W k sCof I �A aCC carrier y rc
n d I(I' ober, , . V,
Carrier: e �9f Policy b
CE TIFIC TION OF LXEMMON FROM W ORKI.RS' '
COMPENSATION INSURANCE -
(This.section recd not be completed if the pcnnil is ba one hundred dollars - - -'
610(ILrr less.)
I rectify tbar in the performance of the work it,which this permit is issued,I „
shall not employ any person in any manner so as to bneome Subject m the Workers
Compensation Laws of Califomla.Date
Applicant _
NOI'ICBTO APPLICANT:If,aftertnaking Ibis Cenifunteof Earmptin i.yea should
becoe sni to the Woods Compensation povi,mo of mus
the Labor Code,you t
Z Z Om
forthwith comply with ouch provisions or pconot hall be deemed invoked. -
F Vi CONSTRUCTION LENDING ins agency
-
j I hereby athnn Ihm them is n construction lending agency fur the PerBnmtvnce. ,
W Fti of Lenin work rnr which this permit is isweA(Sec.3097,Co.C.) t -
p, z Lender's Name
= Z Lender'.v Address - ..
U 0 I cenify that 1 have mad this application and state that the above information is
OF correct.1 agree to comply with all city and county ordinances and state laws minting ^ -
UmhniIdngconumne,tion,and hereby aulhorire repmnenunives of lhLs city In anter upon
`y W [o, 'Nos-mcmtioned pmpenY rnr fn.apeebnn murpmes. _
[r W (W) mcomity uadkeep i ]css the City of Cnpenmo against s
to IiabR f etarocs which t y in any way avenue against said -
U Z City n J-er tsnf Or mum,of his pc
APPIICANTUNDERS'IANDSA WILLC PLY/1}'f.�T�t�c`NON.POINT .3 -
souRCAnoNs ` < Issued by: ( Date
tStg�auta nl p PLm alto Dote Re-roofs -
HAZARD tlS MATITRIAIS DISCLOSURE
Will the applicant or future building occupant store or handle hamolums material Type of Roof
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety '
Curie,Section 25532807
pve. f-11 . . . . All roofs shall be inspected prior to any roofing,material,being installed.
warm,onewram umlambmldfngsmca B.yAegmipd ulityMaid comm _ If a roof is installed without first obtaining an inspection, I agree to remove
it haWill"Is aircontaminantsm defined bythe Bay Amo Air Quality or Management
ch
Dfntri"? all new'materials'for inspection. Applicant understands and will comply with
° "° all non-point source regulations. . P y
I have read the hmardnus materials mqulremenu under Chapmr 6,95 of the - -
Californiallalth&safety Code,Sections 25505.25533 Bad 25534.1 undemmmd that •• - -
if me building does net curmntty have a mound.that it is my responsibility to many the
neopent of the requirementswhich r tot be on prior I a of a Cenificme of
Oc
,apangy� /r Signanlre of Applicant Date
CC Date All r6bf coverings to be Class "B"or better '
OFFICE