00070017 (2) CITY OF CUPERTINO `
BUILDING DlvrstoN _ PERMIT CONTRACTOR INFORMATION
HUILDING ADDRESS ,� „ . - PERMIT NO .. -
H HEATING 00070017
OW'NEWSNAME: ,,, o •� ;{.' APPLICATION SUB DATE
770"CHESTNUT ST _+ 07/06%000 '
PHONE:+� +. I x '' SANITARY-NO. q CONTROL NO,
C K Z ARCHITECT/ENGINEER" BUILPERMITI{NFO
O O i 1 - - , BLDG ELE PLUMB MECH
���
Z LICENSED CONTRACTORS DECLARATION ,y Job DCSCTlphO❑
az o Ih h, fl thtl licensed d p of Chapter J( ' g - y
H with Section 9000)of Division 3 ftleBm IProfessionsC le and"aryl r ,3
L¢ suClass orce d le,. Z� ' L k dG Z—, a' FURNACE REPLACEMENT/ A/C ADD ON
' yy� Date LicenseClassCenraanr
�\^I,[, A CI ITCCT S line A N
C v,0,
` V I , d my pIhans shall'waited us p.bit,records .. -
ed
25 Licensed PrORIO
X .. OWNER-BUILDER DECLARATION
II by chiral Ball am aschipaf the C...munclo,, JecanwLaw(I
C
It, Loll.v�' g (Section 7031.5,R I Prefic,,ion,Code A yly ty - /' t•
which admires a parmitlo colored,alhp demolish,Or reP y structure t
6CC3te prior to its issuance,alsoq s the applicararor such R t to file a signed11
that he is licensed PII (lie patovismin,ofm c moduca,Imu,asai" (Chc,tc,eSq. F[ F7oorArea ' Valuation
co meeting vi th Section 7000)x1 Division3 of the B cine dPnfe: ,Cade);
or Iha,hes enpt fa f aid the bo'. f ❑ w alleged expi ,.Any violation. -
ofSeeton70315byay ppl' [fora,
m object,theapplannoacvil perialry - _ -
of not mare than five l e a dollars(s50) . ,, A'PN Number Occupancy ,
El I,lto,vat,of the progeny or my emphy :-uh wngm nu il :olc cdnpens fon, - 1,9' ioffered ' }said do thek dt ,,act tt Jel H df (S .70,00 " RequBu. ' d profession,c de"Tb c nt r" L d t apply to an "i red Ins-pections'
::wler fproperty Wh h ie p hn h d h work If
I th bar" ply provided fd. b p t
+
x-
:,
wndl or 204 —`UNDERFLOOR -FRAME
offered for saleif,however,the budding or.arproverrecal'c sold within(,ad year of - ti / •^rl,. R -
mplidonthe dw,crb li ,wll have tirebarren fprtoah,that he did I liar ._ 'PLUMB
ry. r
30A. ROUGH''PLUMBING.
ung e r p rp e l ) - r 1 s -r .
❑1 a: ,,, erannep pe+r nexnit,iv tyeantmnrngwll r'eu,ed"eonmdanm 303 — ROUGHI'.,MECHANICAL''',consumer t thp 1 t(See 7044butlers, ad Form Code)The c t rt 304 ROUGH ELECTRICAL '.
LIc L 1 t apply t f property wh b Idminuses thereon: r �.
and n such projects with ,nnaelorte)Ile u ed p imearit tme ., 4 . . I.505 ,—,,,FINAL' ELECTRICAL'
Con lecher s License Low. - _j. r .an' — — x •. a
❑l.uaa.entptytdersen B&PCfarthisre 507 FINAL PLUMBING
'owder 'Date. '008' FINAL', MECHANICAL
WORKER'S CQMPENSATION DECLARATION FINAL';
MECHANICAL
— FINAL ;PUBLIC WORKS
I hereby iffirm underpenalty ofperjury o of(lie Following dti -
❑ I have end will andidain a Crtl!cute elC-. t to adf-inscrefor Workers
p t provided d f by S t ,100 f the I b C I f th
wo
peri f the
work vi 1' h 1 tpstrumn. u d o-
❑I have and all muntunWrkers Compensation finsurequired by Section• - 'V I'� k '
3700 of fon n
the Libor Code for the eronce of the work.l which this nit Is .
saietl.-My Workar'a Contpe nminv lnsurancecaner and Polcy nunberhrc� r '
I -
_ _
Carries '�^'�w XEM TIO 1,,F�IEL M O KERS '
CERTIIlCACOMPEN COMPENSATION
FROM WORKERS
" COMPENSATION INSURANCE to
GRO, ine J lbccompleted ifihe'per n. ifi ti d.eddoll n
(5100) r Its)r _
'�i. .
1 ee employ
that in person
p K a of he k[ which.bjc,permit e issued,1 -
-.hall t pl Y" Y of
n any to _ ..c m becnmc.yuhlecl to the Workers
Can p neat t o Laws of Cal'tor n a Date
n ,
Appludart, -
NOI ICP f0 APPI ICANT k nb th C tc 1 L pt y 1_ I,,
bee o n the W kr:Ct p t p "o .nfL h code y a,, -
forthwuh comply with turn paofaamrZo,the peon t stell he ifiveral.revoked. ,
HCONSTRUCTION LENDING AGENCY
I hereby Ilion ther flead is lieravartarlina leading eigme,forma retiornan e
of the ivdrk far wbsh Ji pert Jt'. n hell(Sec 3[IY7,Civ C) , >` - - '
p
L>J Q 'Lend N ne wbf '
7 Z Landerf,Address
U O 1 cert fY that I have I this 3Phcdfiavm add dat thin he ah, f i '/
correct.1 agree to corojily with all city and county ordinancesant]st i Int ng
[� -
lob buildg .¢action,hall hereby authorizerepresentatives of thiscity to enter upon
tNe aleme-Owalamund property f .I f e ea Pn e,
6e (W)agree to arod. nJ m ify il keep mannalre,dur City of Cu,dIm.against
i Cit
liabilities,judgments,cosis and expenses winch may inany way arcerear against still - tUNDERSTANDSAN
AP •�'
- G City ne ....ovate of theg ingofthis p tet
SOURCE REGULATIONS e - ��Yy....�.�,�J J�
PLICANT D WILL COMPLY WITH ALL NONPOINT Issued by Y �Da[8�,� V V
r
. Signature of Apeliant/Canraider Uutn Re-roofs,
HAZARDOUS MATERIALS DISCLOSURE - + -
Will the applicant rt Nothingoccupantd handle h '1 . -n al Type of Roof "
,d,fired by the C p t M i Pa Chapter9 12 " til Health d Safety
Cade Set 2.5532h.), t
- oY "'" All roofs shall.be Inspected prior to any roofing material being Installed;
I will heappr Cilia f t b - p t .-ngntl t d, devices wit"n If a'roof is installed without first obtainingan ins'ecdon, a ree.to removee.
emilh d cont res tell by lh ByArenA Qully Mauagemm�t p g
District all new materials or inspection. Applicant understands and will comply With
°Y°a °"° all non-point source regulations.
ba
h rctd the 1 t 'el ny t d Ch pier fi95 011e, t `•
California Health&Safety Cal Sections 25505 25513 and 25594 1 andandand that Y
I -
occupant
cupa II' gd uiremenot rentlyh t nt that t'. y .p IfaC fly th J -74
� y
Oce p to t the y ire is wh ch nue[b t p r to icsu ns of t Gen my f —/—[w—.(AV"7 ��_
p Y Signal ure,of Applicant' 'Date -
r -
x Owner arauthorae agent " - Date. . .1 All roof coverings to be Class B" or better
.. , - OFFICE.