00080023 (2) cl BUIOF e DPERTNNo PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMITNO,
F.I_11(S ORD UR loll Eia_.E=CIRIC: :Celt: 0@0800(12:3
6 OWNER'S NAME APPLICATION.SUB DA'I'S
LIM30P1. 5255 S"fEVEN9 CEiE_IHY 14 V 0.3�7008/IJ:3/i?(%00
ZONE, - SANITARY NO. CONTROL NO.
(408) -. 66-0 1.00
P,O O ARCIiI'1'ECT/EH4 INFER: .BUILDING PERMIT'INFO'
.�a, BLDG ELECT PLUMB MLCH
CI L`J t✓I .1=1
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" LICENSED CONT'RACTOR'S DECLARATION - Job Description
Z 1 nemb affto that 1 ran licensed kinder f Chn ter9 r
y pmvisions o p (nmmcndng
F,e,rJ with Section 7dfHq of Division 3ofthe Ba,in.ssaad Profession,Cde,and any punese
tam m6mncrmndefom. Y ELIEEC•T• UPIGRADE 200AMPI
e a um.,e cl O Lie.a
°sQ ie c. Date_�� v-� Cmm�,nnr �T—
c. ARCIIITECT'S DECLARATION
C��� 1 nnderstvnd my plans Shull be nsttl is public records t
�Y
'Licensed rmresmtwl -
OWNER-BUILDER DECLARATION _ rr,
n m a so I hereby affirm that I an seenin(roar the Cnntraanr's License Law for the `
following reason.(Section 713I5,Brr,av,s and Professions Code:Any city or,runty
T F C
which reports a plaral I construct,ah P diOndith.in rcpt y r,'uctl rc
to prior r t 1...cocaine,ther,ah,conr b pit 'u file g d:etcmcnt -
thin he is licensed pt to the provisions oft C n t License L (Chapter 9 Sq. FL Floor Area Valuation
(conn ¢ gwthSect7000)of D.... n3 fth Bine JP f..' tsCode) < ^
kir that n aempt do r and due ba f m llgod e pt a Any'violatiion yrl(%IC)
Orria morection e urn Fee to tundra Lade,(ssoo).tsubjects ono apt f- t t d penalty APN Number Occupancy Type
❑I,iosica.ftneIF peny,ormycnnployecswhnwogaaaneilson,cmnpetaadoa, _Fs," . .G G)f�)
will do the work.and the orumure I,act intended or offered for sole(Sec.7044,
Resines,sad Prnfesaii Code:The Cnntmctnra License have does ao apply to an Required'Inspections
w r of pperty Who bddds or mnpmves mre
eor,sad sun.does such work ourself
or tmmrough his Oven e,oplayms.provided that such enpmvetaematlo not lmmndeJ or 304 .... Iri0U131-1 ELECTRICAL
offered for sale,IL bawever,the handing or improv nstra Is sold within one year of
centpurl)on,pro nwreohuilderwill have the burden ofproving that hedid a.,holder E501 .... f":I:NAL ELECTRICAL li:.'1,l.'ROY
i,npmve for parpwe kir sola). 505 -- F'1blAl_ ELE:CTRICM.
❑1,as owner ohne p,ope,ty,nm c.,] 'ply contracting with lia..ed eomramors m '
construct the project(Sec.7GO,Business and Professions Cod.:)The Conunetnr's
License Law does not apply to an owner of pmpary who builds or improve Thermo,
and who contracts for such projects with a contractor(s)licensed pursuant to the /
tracmr's License Law
an,c,cmpt umdor Sec. ,B&P C for this reason ,
Owner 'Date
WORKER'S COMPENSATION DECLARATION
1 hereby off nn under penalty of perjury one of the reproving declarations: - 0
1 have and will maintain a Certificate or Consent 1, scl F'msure t
for Worker's
mpensmlon, he oak foal for by Section 391111 .f the Labor Code, for We
performvnec of the work for which This permit is'issued
. - � -
❑1 hove and will maintain Worker's Co 1peneation laskinkiice,as required by Section -
39fN1 or the Labor Code,for the raformen.e of the weak for which this permit is
,sued.My Worker's Cmnpensation Insurance currier and Ptdi.y number ate: _
Can'mn Policy Nod -
CERTIFICATION OF EXEMPTION FROM WORKERS" '
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred JNlurs n
($1 00)or Ices) ,
I cenify telt in the performance of the work for which this permit is issued,1 y
shall not employ any person in any insure t bled to the Workers' „
Applicant on Laws. aliforni; t�W
NOTICE TOA I. ANT: L A kmg lnt mt¢a,e elEsc
became subject,the Wal kch Cmnpensutin.pmvisions of Tec Unfair Code,you matt
Q p forthwith comply with such Prov l sines or this permit shall be deemed revoked. - -
Z rr .
(~ Vi CONSTRUCTION LENDING AGENCY
a 1 each,affirm her there k a umxtmchou lending agency for the Poffonnurno
of the work for which this permit is Issued(Sce.3097,Cie.C.)
Q. (> Lender's Name
z ,Lender's Address ,
V 1 certify that I have read this application and stale that the above information is
6, E., carate'.1 agree m comply with all city and sourly ordain ces nocturne laws rcluting
0 V to building construction,and hereby authe re
orizpresenuvives orchis city to enter open
he above-meatb,ned property mr inspectimn proposes. i
ley'
(Wor agree it)save.indemnity and keep hvnnless the City of Cupertino against -
r Cn liabilities,judgmems,costs.sad expenses which may,in any way ammo Dermot said
V f.'PPLI consequence R lee granting D WILL
APPLICANT UNDERSTANDS AND WILL COMPLY WIT
yALI/NONPOINT Issued by: Dale
SOURCE BFOULATIONS. d+/ )_
Signa
if
of Apprcan✓cmmotdn`�1 yV J'•Dat — Re-roofs
HAZARDOUS NINFERIALS DISCLOSURE -
wdtheappl,.aatorfrarebailding oeeapen sea,Or hv,all,hOundona oderied Type of Roof
is defined by the Cupedin,Municipvl Code,Chapter 9,12,and the Health and Safety -
Code,Secd.n 25532(a)'t !'
oven 0 N All roofs shall be inspected prior to any roofing material being installed.
Will monpphevut.1future bnddiagratupartareegaiponaradeviceswhich If a roof is installed without first obtainingins ection,.l a ree to remove
run,ha...eras all c,mmninunts us defined by In,Be,Area Air Quality Munagenuen - an P g
isupeR all new materials for inspection. Applicant understands and will comply with
❑t'es El No
_ all non-point source regulations. •
I have read the ha,andous mate�ials requirements ruder Chapter 6.95 of the
California health&Safety Cole,Sections 25511.5,25533 soft 25534.1 understand Ill.,iI the bunch ng does nn,currently have a team,that it is my responsibility[it are fy the
ccupar(at the requirements which must he n,ct prior m isnuu ce o a Canificane of "
n l Sigha[ure of Applicant Date
owner oraumo,i.eda kit Date All roof'coverings to be Class "B" or better