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01050172 (2) CITY OF CUPERTINO -�'" ButLuiNG DIVISION PERMIT CONTRACTOR INFORMATION: BUILDING AD DRESS: ' - PERMIT NO. 1022P DUBCN AAV _ e OWNER'S NAME: - APPLICATION SUB DATE EABAr r , dex,.. � •�y;s, i • ..!'asst"�": .t'+' -',. .:.:;r`a . +�+ sP ID:.f'f,..c'c/ti_t,U 1:. . HONE: SANITARY NO. -CONTROL NO. l _ C,K Z ARCHITECT/ENGIN F.F.R: O O ? - BUILDING PERMIT INFO w" @ ° HLUG ELECT PLUMB MF.CII Art {gu Uy. d - . t• � `��I Z6 N6 i LICENSED ONTRACTOkSDECLARATION N z5„Z ytm my ' JobDescriDescription n OstI h by I sed I p fCherie wthC9100dIh, ufheN IP R' nIaye 1 dI if l T410,��- Lie CONC Counter 9T S ' - - AtCHI - ' DECLAR ON _ FKI rourecolluardray Plains shall hetcd a,Tbl' cords y00 Li dPnl'es oral OWNER-BUILDER DECLARATION. t - I�i -1 herchy Ilffnn that 1 um csentpl front the Couln¢lor's License Law to,the - .1 - . following retain.(Section 9031.5,Hneiness and Profession,Cade:Any illy or amity y` ' u�i Cm N'inch 9'. e Ill .til n p J III p y:in,�tre .. .. - 1 lfl a11f II njw ttl fl g d ca e l _ that he f Ip t o II p of the Contractor L La (Chalfant) n. _ ,m g,with Section 9000) ro ,of the H aP r,a .cd). ' Sq. Floor - Valuation - _ arthat n -: ptm r d.tn n f -u ll ged vl ny ' 1 f _ ",r ♦4aA,.. .,�y::.,r.:5;74300-- . ofSection 7031.5 by any applicantf peordir subjectsthe' . applicant a yIp ally I _of el narethanf„.n handled APN Number 'Occupancy Type - rCl r dlulth,epr,arl ,ortoy enplyeeswith wages a.me -soldomm�amn. ' a[4P440 51 — wl h work,a structure Iintended r IT J f (See.9044 Tipsiness 'ef nis Contractors Iice - L ° n trally 1. ;un r f property Wn drfp there d h J e h work R _ R1�eJq13u-i�red Inspections rthrough,h f. • ply p ddo l: 1 p nnl intended 303,.— ROH ,MEEHAt offered f of If,h II building mpnnwtem ; UNTCAL” Ithno f `oiler .theto bld 'n have the btmenafpn,. glh-tnedidloth Idor ROIIBH ELECTRICAL up frPnrp .ear:I > ' t - OI a of property, y .."ll,licensed nt Its to 505. — F,1hIRL:,ELEC;TR'ICAL >, 'u o t La project(S 9I.a owBusdP- I : nC 1run C tunotn, - - . License Law does not apply m a t owner of property who nt'Ids se Jousp rmeson.Can 9 t for such pn,Jeds with m adnr(x) licensed pt r anl,m the •-¢, - Ct t� t I'�nsc Lml, su - .. ... �. O I t." Pt under sec. B&P C audit,reason - or Owner . Dal. WORKER'S COMPENSAHON DTC1.ARAl'ION" Iheteby nffimt underpenally of perjury one of the follotrngdueluareions:♦ , _ •�D p I h I I l - t l t C t l t f Consent to 11 r for Worker", a a ' r-I N A L ° Co p r s, P y velloar . 'of 'We Lub., Code for the • A MAY _ pea 1' At 1h m'.pc ( Hot '. ul. O 2 1 „ soil and wll ur ;tefora Worker's Coulloulat mfula.- y fb Sector _ - a. .S9 of Inc Labor C d,fir the wrfor w of the weak for which this per nit Is - .. �• " ,led M,W kor's C nD allon Ill, c er and Pnl cy lumber are -f .� Ca Tri ier P, ' - -BUILDIN CEIGH O I 1 R(lM WORKLkS r ' ' MPENSATIONINSURANCE , -. - (Th' i tend not be couplet d if the pcnn t-s for one ht ndred dol lura I .. SI00) - I iy0ty that ill'Ile gerr to, of n rk l hich Ih pviond surd•I shall roof track,a it,pn t in any na r a♦In wernar subject to the Workers Compensation Lowsof Califnmle.Date r ¢ - I Applicant, NO]ICE TOAIII ICANT II afte,oseldr,th Croule,oloot 1'xampftn,you shah Zhertile,object I (he W k Cianiverctiorpro,souns lifIficl.,bo Code youmist firth 11 ply r.'th h p ' II s per n t shell be deemed revoked - ^'� CONSTRUCT ION LENDING AGENCY W oI herebyt there L a on lending agency f r me performance f the work fill Inch'his p mit is issued(Sec 7 3099 Cie.C) • Leader's Nuue z Let d AdJ e s - �, I Ifyd tlha cd1h: ppl' Y uhc h f a , [� correct or e I V ' p1YIhI agreeI county d' t 1natio, mbuilding t a n tl [ mpresentatives of(hi I t t - t1ic M1 snot letyf :pct ptp. P i '[y40. (W)a to or 1 Is andkeep h .th City,- tpdojer ug'. 'I •,r h (tab fin" "rent.. I. 1 espouses which Y ill an y tame against:tit "V Cny : l roofll N rNDWILL t AT CA NI ULAIIONANUSAND WILL CO WITH ALLNON POINT RCE REcuLAnolvs Issued by: Da'te I slgnalufeofA, I oIt pan `'.Re-roofs II MATERIALS DISCLOSURE ''" .marmmrennuantgmvtpamsmrenrnandlehamNaa.n;mndm Type of Roof "". . . as dertned by the Cupertino Municipal Code.Chapter 9.12,and the Heath and Solely -_ Crew:Se6ti,an 25512(a). or- ON,, - All roofs `shall be inspected prior to any roofing material being.installed. w'u m ppi t r t n 116 n qn'p t d ° a wn'm If a roof is installed without first obtainingan inspection, I,agree to,remove-' endth d nil I.asrefined by the BayAeaAr Quality Mtugener, p "i'' all new materials for inspection. Applicant understands and,will con, 1, witb, ❑Yex °" all non-point source regulations. PP f compl, 11d the Ir N oat I: q -t:mWe Ch pt )5. I me _ - Callf aHe Health f Iy d Seel .25505 255q anJ 25594 I In'1 r Jthm file M1 ld g does not 0y h_' utan ml ll 11 . ttY resp bILW nmif this _ oceupa I f II req or t -hh nmt 6 1 pr m Issl Certificate of - t ,Occupancy. - r p: - - ♦ - . 5 Signature of Applicant Date Owner or aunt -.ea ltgon -', Date All roof coverings to be,Class "B"or'better • w OFFICE