01080135 (2) CITY OF CUPERTINO •`
Bull.DING DIVISION - - pERMIT CONTRACTOR INFORMATION
'BUILDING ADDRESS ,; '. � ' ' - ' PERMITNO,
PU.)hIN11,10 ROC F"11%10 C.t
OWNER'S NAME: APPLICATION SUH DATE'
Ii611:IhI 1 I(-1f2Y .(1. 383hl,: ° Fl E 11 • Illi_: ir 00:1.
PHONE 4 SANITARY NO. CONTROL•NO
" .,��+c-rte) 3�rr t1�+'s:''. •' . "
❑z Z -ARCHU CIRENGINI I R t - BUILDING PERMIT'INFO
mF ' BLDG ELECT' PLUMB -MI H,
a e, -
'y
z4 3 - LICENSED CONTRACTOR'S DECLARATION lob Description t
O Z 1 1 h r by of it m Ib I r l censetl J p f ChoDler 9(commercial, 4
I 9BfgJ ID 1 frac Bu dP f:' C atdm)li
me e
r� ItI
mlSur erre ( OS3 ` Ilfll<I'r:ae I)P f" .'kf) YI til'-'1'ifi::i3;. ;
° oweo.,t ctn#acntr .. ..
I cd y: ARCHITECT'S DECLARATION I:/f,).; IDLY/ Ill 'RC)0I::;_- '
yI d i n any plans shall tie n.aJ.a panne reeom: - ", -
ce
a �a LicausadP i. ',tri3 .
OWNER BUIL DFR DECI ARAI ION
m-m I hardly R- that l pt f theContractor's L L for the v ��
1" Q
following
(Section 7031.5.B :' - d Professions Code,Any city county
�a ❑ wMl 1 permit l construct h p demolish, p y11 talc r
]i6 pif I t 'I. t1 ppli tf Ip li t 'y d.tl,nent
Inns n l p t to the provisions ofthContractors Licarl La (C1 pian Sq. Ft. Floor Area _ ,Valuatio
('e clue tib with Section AH10) f Drak t 3 at the Bus na nJ Profession,Gude) y ,
or thin he a e m the fr i and the basis T the Il,ged asainplion.Any violation _ � -
of Searle.7011561 y applimunf ' 1 subjects the tpi l civil penalty `
ofnl nnamathoa five handonddollar,($500) APN Number - Occupatin1 olno
❑1,asowneroflheProperty,nr my cmpiayces with wages as beirsole compensation, _will do the walk..and the structure is not intended or offered for sale(Sec.7044 - -
Business d Profession,Cale The Contractors Lice a Law does of al ply I an 3;1.(�:i3U(:1�+ldetjUlz'ed Inspections -
owner of preparty Who ha ds or improvei darcvaa,and who does such work himself
n(h au] h d.,e P Jed that 'hp t t' t ad d' t "
offered for saic.IL howeve,.the hulling p i is suld within On Ye f "
completion,the owner-budderwllhavem b denolprevngt to hdnathand r 3fA'Hd I Im:(YI''lla
P on pnmq,e of 1r') t.,3 if
Cl 1,as owner of the property,am exclusively contracting with licensed ciandrarbin,I.
construct the protect(See nw4.Bushes Profes,ims Codh c ntractor's 601.. ,R00l'- .TEAR01:I , '
,c Law des tot apply I owner or property sena hu I i l :0 rcon " -
aw n I aeL m. p i tF wn;a aonnaelmrf,) ..ell pitmnnnl,ra be - - _ C C�)r.'. .,t-,-f2[JIJf I 'I.YGI(:)i:)S) Llflla._�a..., - ,Contractor, censeLaw. I a 'a ` - -
OlamclemptunderSed if&PCfor,Jrnraasc... (i(%) 3 12C)[]I' -lural Tl:_bIF3
Owner 4 4 .Dille a.. . F,04 ROOF*
WORKER'SCOMPLNSATION.DECLARATION ,
1 hereby alYvm under pcimlty of perjury one of the fallowing dcclurehnn.0 _ - .,
0 1 nave and will mainumn a Canlfcata of Consent to Heir-insure far Worker's
Compenssation, as provided to, by'Section 370o of the Labor Code, 1'o, the
pelf of
Ih a k bar whichIfifix pat I mel. ..
4(��Ih laid II ant ' Worker's CnPn I . �Iens required by Section
N
9RID Of he Labor Code his the parlour a ce of the work for which this permit Is
ssucd.My Worker's C t t Insimnre comer and lint a nu ober me e •b•° ,
- •„^ - - -
1Y' k�� " (y v,
Cartier. Polis Nn: J -
CER'1'IIEXEMPTION FROM WORKERS' -
COMPENSA'I'ION INSURANCE
_< t
r, (Th', ham nepJ not he con plcmJ If Lha par n t isformuchundmi - • _ ,� - - , , -
($106) 'less)
I r ify it art,
In the r army ice of tl rk for which this mail t s ssucd;1
Challmin not employ any parson I aany manner sn;u to hems,subject m the Workers' - -
Cpplica salion Law,of RJifnrnin.Date ,•
NOTICE
OT can
N ...no:obj APPLICANT If afar mak tib Ih-'C ft I E pi n'you shm Id' ,
M1ec subject In the Workers Cmnpcasmtlon pro , of the Lucia Cote,you toilet,
Ponnwethcon l-wilb. fi ennnnrlhs rnishtJl bo Jaamc vn- 1• - . - � - .
Z
^F CONSTRUCTION
ofLENDING AGCNCY
I h h that construction finding agency
fm the prfannmtee
d for this peml'x w.weJ(Sea 3097,Cie C)
Lenders Nan
-z- LenJcr'e Address - - - • ' � - ..
V Q r . '1
certify read lyanni tl teeth)ill b f.....te
LTi try 'correct.IgE t comply Ill
allilyanl ry rd' a f(is any relating
C'V mbuilding coaslructi property
far o authorize xprese mai nee of(his any Meme upon p , -
• 0 dha an t o s e, Iy f 'Pel p T
{.i p,J (W) 6 Iindemnity',a O which P h I the ang itywa wa I n y -• 1,
U V1, City u c j I6 t t -J p :. erre may in any 1 eerue'agi net said,
-
C.1 7�- City
.q .•of th trading of this p nil.
APPLICANT UNDERSTAN S AND WILL COMPLY W I PH ALL NON POINT ."� Cl �.
Sou rceRc iya Gu�ArT�IIDN - ,,a Issued by:, .' Date .G
SignfApphwbConrucmr Da/�' Re-roofs
_ HAZAkUUU A'1'ERIALS DISCLOSU RL _
Will the applicant or fro m,building rcupam,tar,or handle havarchms material aType of Roof r - - r{'t•.
as delated by theCapen'` Municipal 1 Code,Chained 9.12.and the Health and Safety
Code,Section 25532(ul^. n r,a
°YC3. n. All roofs-shall-be inspected prior to any roofing material being installed.
Will the perm t r t en illi�ngo„tnp-nt�soa,up t de aswhicn If�a roof is installed without first obtaining an inspection, I agree to remove ,
emit h 'dcontaminants defined by the Be,Arse A' Quality Mamage ent ,
Disl'a, all new materials for inspection. Applicant understands and'will comply with
°Yea 1N° '' all non-point source regulate a
I have lead the hazardous materiakq r is ander Chapter 695 at the - - -
Cefifino al Hihh&Safety Code Scannell 25505 5511 and25534.1 andersdardtht s -
fthebuilding ones not currentlyhave a enter,that It itY Tallonablinyit)notify ll
occupant of the requirements which tit met or to issuance of a Certit wl V
or'`ap mey pr f t Sig •ture,of Applicant 000, biaie'. ,
`ow or aaotari.ed$tgem - . . Date All,roof coverings to be'Class "B"ortbetter ,
OFFICE