00080019 (2) CITY OF CUPERTINO ~• '
BUILDING DIVISION RM
PEIT CONTRACTOR INFORMATION:
BUI DENGXL*0$ 37 ISfi: 'f1bIIGa -ksl_VU ^ PERMIrNQ.
(j(%J[tI1J(d(J:I`J
ON
NAfit(,'l.l.a_' fir '(.,Glrll:,0blY� ° m is •`N r APPLICATIO,",9Ar4/P_L((300 ..
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.q r SANITARY NO.r 'CONTROL NO _
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.c a O. ARCHITF.CVENGINEER: „}• i , BUILDING PERMrI'INFO
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LI ELECT PLUMB,, MFCH' ".
- I ICENSLD CONTRACTOR S DECLARATIOM1
o z o I hereby B that r f J p rcnary 9( g - Job Description
,� calms f n9000) fD' n3anhe Bt am Pn,rnss nose me u,d inyi r- . • SER
a
is I,fall force ndohext' i C111111 :Eif I 'll: W(aTC Is. aE hVJ:GF�
�� n<e ecm a I LIITIITII fi[ 7f1L. W61T1 Is ')E'MICE
Say nm - 2C t- t
ARCHITECT'S DI CLARAP ON -
�LL�,�j 1understand IPI hallex d pbl d - r
.wa. 00 Licensed' P f. ' - h` �_ -
k r4,tai. OWNCN BUILDER IIFCLARAI I0N
w—m Ih by B dual1 "x pt1 II C I I I' f the
I-' Q
billowing IS 1 7031,5,B . d P Code:Any ly ly •a, pfi �
•�F n 'hich y p I I n t t II p d li'I r-pu y sI t ,k Q '
a3ce prior to t issuance,al. r 1 the ppllcum fusuch permit tI signed statement �• �
math licensed Personal the p s of We Contractors$ n' Unix(Compact 9 Sq.�T"'t. Floor Area , aluation
(commencing with Sectin 9000),flDivis 'T thefBusiness d P obis ens Chad c)
or that he is exempt lhcrefmnad due basisf 'tl Ilg l pit Any ruin. $AOR
'of Saw m901L5byanyapphourfor itp 't. nit Potha appl'amn uu vii li�alty -_ -
ornm mare than Irv,hooded du1Wm 500.'
^ (s ) APN Number �A�' Occupancy�Type
� '
P Y
°1 e- fth,, p tY Y ply ih 6. th' -p ..usury C:'r,'. - Y .
will d the k th h t tintended ft d f I (S ]044• '
Bushiness..,I P f :icCode m Contemner',L L due,net apply b air - ,Required Inspections ; .
ow rofpoi Who builds p- tit J h J h work himself _ ^
f through bis own a ply ..p provided t n improvements tiintended m :L fel(-.',. =-• SEWER A WATER .
offered for sale'11 ho thebuildingimprovement u, m within one yur of i _
completion,the owner b 'IJe 'llhmc theh f ip rving andho did no(huilJ or ^. L:�(rJ2 "" Ul lDERl' L..Uf.fl'l TI h, .(Jlrl A.i,Elul(:)
r - f f ,w,nl le) +,
❑I came, f11 p P try amen ly I r e a 1 d t t t `�. �3O'I. ROUGH 'GIL_UITIH7:1>IG '
mru t thej I(s .904a B Code 1 Th Co t -. .1.30P. •I•UD & OR £31-OWER
Lce: L d I apply to owner eft p ty who bold -improve,bureau . t -
and n k r '1 projects with t t�rc7 licensed p . aatmmg - .:Fii(%1a -- I":CNfll_ I�thUMlEsf NLi ENERGY :... '
ConVUCmrs Luwnso Law. _
Ian axe plana see Brsr ar.B.,re. _ a(<6 G615 fl:.s.r. .
Dow
'r(]7 FINAL ,f^'I_UITIII1,10
ORKER 5 COMPP lYG AR
I herebyalfinnundai penally of perjury one ii following declarations:
I h J TI o t' r' I ec f Convent to: L T Worker'se
amp n,f n s pro 't d'f by Section 3900 f me Labor Code, fob th t -
crf rbc work l which ti's Remon,t s L,ved. � � � t � -
1
111 have d will int W kr^C p f I .ua - ^
39011 of the LL Cod I theforfeitures,or the work for which tohM t'.issued M Worker i thoum -s tdlnit h rare: . �'. S •,
My /y
member: Polcy Nn. WORKERS' - - '' I -
-CLRFI CAf1ON OI'$%EMIT o FRO KERS -
,- - COMPENSATION INSURANCE' I ' _
([h i inced uet be conpldcd'finep It is boron,hu udPcJ dellirx '
4
J ffylhtrt' II p f - � rlh work 64 which this"brt':issued,1 t '
ahull m employ any p u n any n i s m hcwme sublcia tri the Wo k r �� �° It -
Compeuset on Laws of Cal fi nim D,term n
Applicant .e NOT ICE TO APPLICANT If, fl ranking thisC n s to f F pt y should
hec bit tt theW k L pc. t p f die Labor Cod y oust `
.�'Q forthwith comply with hprovisions or his permit shall be deemed revoked.
^F - CONSTRUCTION LENOINC AGI NLY r, '
11 'eby affirm that(here t I t' leading' age y l tI a performance
a ander"
k'b wti LM1 th perm lir eaued lS 3119],Crv.C) ' .'t,. .
� Q Lnndra Name. r 4
Laurie,,Ada i ' t
V I caddy that Il Ith ppli r Lum thin h t -
Gs. F
traded.I g t ply tit II ly J county N d.tat-la lm g
mh Id g .I i JI by' th p n hive, rth -IlYlo2ntur pm
the:111 mwtimi d p p ty f r In.pe ll n p r,asee. a
91.1 (Wc)agmeto save. d 'ly dk ph 1..'heLty fCp t g n't
rs
liabilities,J dg Wena t.- d expenses ti ch y li any, Y'accrue uga net 'd
.V City y they Eng/Ipnit. p , o- ,
IL NTl ,Rs k DS 4D WILL MPLYWITHAL$N Ns.�PO ) 3_pD
a a ,O Q Issuedby: - Date
sig ore of Applicam/C a or - - 1 Re•roofs , - •; 'F .
t HALARDOUS'M ERIALSDISC'OSURE
W'Bmeappliaa t future hall ng -p' to rn n trained....armorial �'rype of Roof . r
aster,sdby the Culreri hlun cysalCW CI pter912 a Ith 11 Ili dS l'ty ,. ^ r.
Code "action 25532(a) /` 414 9 _
°vex 'm b ' All roofs shall be inspected prior to any roofing material being-mstalle'd- '
Will the aphicaut or future bur Imng fa m use cyu p t d s'whidt° j without first obtainingan inspection, i a ree to remove
ot
Ifaroof is in'sfalled w t out -
mit h N veno ants a defined by Ino Buy AreaA Q I ty.MetiSgcnsnt P g i
Diane'. all new materials"for.ins ection. Applicant understands and will,com I with
,Jq, ,. P PP . P Y
°vas•' all'noH-point source regulations. t
I d th 1 d i al q tuts and Ci a pit 695 ache i'- .'t _ 7,
CaffmiaHcaltherSocry Codc Sccions2550525533 ani l melcommul mut t
il'tholutudingdecsnoteconardy haven rit,, hm b
t ilehilayornailye
der, t h netts which burr t ti y�s
t p a f.Com t f
res�nst,aan Signature of Appli anb Date
r
elaborate a,cet are All roof eoverings:tobeClass B'.orbetter ^
.OFFICE
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