01090093 (4) CITY OF CUPERTINO "
•t')BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDINGADDRESS:. .. _ PERMITNO,'. '
10535 S FOOTHILL BLVD ' 01090093
OWNER'S NAME: .. _ .. .. ..
- _'" ' -"' � " � - APPLICATION SUB DATE
, IMWERNER GERTRUDE A 09/20/2001
' PHONE: SANITARY NO. CONTROL NO.
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o
i.0 0 ARCIiI'fECT/ENGINEER: BUILDING PERMIT INFO
z'U BLDG ELECT PLUMB MECH
'LbC
xI� ri Ibelebyaffirso OtIam OCMRAdCmRpSDECLA rf Cmp1 91rymmenc ... .-. .. .Job Description .
j
:�2E SCM section]x001 pf DI a 3 fth Bu dP t n C d dmy see g .PANEL'- UPGRADE/GAS '
r��< IZ'ttr(ullCls utdef9 3�r'k;';,', a- " ORIGINALPERMIT 52182 DESTROYED.'
7 3 c. Dale Contractor
ARCHITECT'SDECLARATION, .d FEES PAID ON ORIGINAL PERMIT.
.L3 " I uadcmtami my•plans shall be mud as public n,coidx'
3 6G O Licensed Professional . ... '.. .
'xM
:a a 'J, n r .OWNER-BUIEDERDECLARATION
w-,n 1 hc4by
D wthat I m pt from the Cf the
?afollow g reason.s u 7031.5.Business and Professions Code:
Mycity county
h ch ts Permit t t,alter, ,
"
rmprosu demolish p y structure
m
=its c 1 W d iltaxiof for x«bp)rmnt is signed to x .....-
°' - SemM1e Imi it p int t ilia p i sof See the Bal Li ala ICs pm 9 .�i, 2 1, cQ Ft' FlooC Area `'
or m nn e with Section om and
he basis
3 of the lege, add Professions Code) J t'q 1 s D k s I .,) ,,r P) ,y 4. Qajluatioh
of Seel be rs)nemyt therefrom end Sec bests for See am On plica ntto Any violation - - v
_ --ofgatiov]03136y any➢pylic➢mfor a permit subjects the applicantm•civil penalty '
of not mon,men five n➢ndrea douars(S500). .. 3 4 2� �Dftt�56 i Occupancy Type
01..owner of rhe propsny,a,my emploY)ea with wages as their mic compenssam, _ t
„ will do the work:and me structure is not intended or offered for sale(Sec.90,14,
'Business and Pmfi,,xions Code:The Comrecwr's License Law does not apply to an 304 - ROUGH EIAR d[ )tions"" " �' •- -
aw«oughhiis rtyow Who bwmaarimDmveOmsuchiand
vementsmsuch tinthimself 501 - FINAL ELECTRICAL ENERGY
or through his own however.employees. budded mat mer improvements arc net intended of
offered for sale.If,howevere the building or improvement.sold within one year of - --' - -_ ---- -
ampladon.the awner-boil,)fwiunavethebamenarprovingthat hedid nor bu,,« - 505 - FINAL ELECTRICAL
mprove for Durpou of salt.).
. . _. _ .. ....,. ne _ .. _ . . .. ... .... ._ i
❑L r owner of the property am exclusively comracting with licensed comr«mrs m --
'- ' constmrl theProject
a t.d (Sec, 1. Business and Professions Coaor 9Jm Convaream. `
License law does Iwt rapplysuch
man owner of pmpmy who ballon or improves Utermn, - - "' - •u
and whD.mnnaru for such projms wiSe.a conmacmrts)licenscd.pursuam-m the,. t
Co Im Ltc a Law,
❑1 exempt under 5 B&P C fo this reason - f
OF
� .Qwnery .J.i .eY P,�:.,Det L 1 n 7.V : .. "
_ff YgllM1y�bY nRtinRKunder
R�OM of perp ry�n�ofCihe following . req-
` '; . •,., •. „ .....,q p
ity
—, declarations. NOV 12 2002
{t ❑ 1 have Wand will maintain a•Cenificate of G maran m self-insure for Worker• _ ,p p� "•
6�
Compensation. se i%o4idM for by section 3]00 of me labor Cad). f« Ne B{JIL®97tl�
perfoin,•M'of die work for whirl Itis pcmdt is issued.
❑1 have and will n1dan in WoikCl i Compensation Insumn«,u rtqumed by Section
t. 3700 of he Labor Code,for he performance of the work for which this permit is t
;.,' is"sactl:My Workers Compensation Insurance carrier and Policy number am: - '
EPolicy No s .,
CERTIFIFI CATION OF.EXEXEMPTION FROM WORKERS 1.... „ i-4 '�5. s.h r t lk, t.r s: i_ •5 S e.A.Y
�:,:...:....;.:i.._.�.;.COMPENSATION INSURANCE.,,' . .. ,l
................._,,.._. _... __.. . ...._-....._.
(This unlo'n nest ria M rompinW ifshe Permit is for o«hundred ddlux f ._ -- fC
4100)or less
r ::: _ _._ .._.
_ e
I eenify Sem in me Fein anyms of See work for which this permit rs rssu)d.I
P Y, Y re y maover»as to become subject m the Workcn' - "j' ti 1""' .: =\'l
hall that Cm Io m Persian In➢n •. .• .
Compenusion Laws of Celifomi➢.Dale "
. Applicani -
NOTICE TOAPPLICANT"If,after making this Cerificam ofExemption.you should -
Z become,subject to the Workers Compersition proo isions of the lab«Cues younman
forthwith'complY with such provisions or this permit shall be deemed mvaked.
Z .. . . .. .. _ .
"CONSTRUCTION LENDING AGENCY
'I hereby affirm Sem there ix a conswnion leading agency for the pendoimaace
Of
Out work for which shii permit is issued(Sea.309],Civ.C.)
.d Lender's Name - - -
I ..nr'x Address
LUL O w„' 1 mfY tout{h d m and at tic th t th e f tion u
F cone t 1 Ogren,- om
to cply w th bol city
and and taounly md'nance.,andd circ Iowaer upon
iobulove conxlmciionadheietiy authonurtpre nmtives of thnarymanar upon , -
sj,,.W she above-,homed progeny for inspection purposes.
q eWe)agree to save:indemnify and keep mdmd e6 See Cay of Cupenlno against
W liabiliii)s,judgments,coin' ad expenses which may in any way sector,against said
City in rxsu rra)ofineg_.,n.ofthisFormic,-
- APPLICANT'NDERSTANOSA."WILL
COMPLYWITH'pELNON-POINT Issued by: Dale
SOURCE REGULATIONS. 1 :'
Signature ofAppbcae/Coni bur '-- ' Dam Re-roofs '
HAZARDOUS MATERIALS DISCLOSURE: .”
to
Wdl'See, jificaft or to..building iron,at handle licardoin mataan - Type of Roof
as defnad by me Cupen Municipal Cod Chapter 9 12,and See Danish and Safety _ - - - -
Cade,Sen on 255321))7 P t I 1 A., .. is I'll,' ., t e i
C)yes °N '! .-All roofs shall be inspected prior to any roofing material being installed.'_ .
miWdl the applicant or future building occupant equipment or dev ttx which If a roof is installed'without first obtainin .an ins ectidfi, Pagi'ee to''remove
t harardousair contaminants se defined by the Bay Arca Air Quality Management g P
O
r """" - all new materials for inspection. Applicant understands and will comply with
1I f " - YT a [7 Na .. -
Ilhave'rcati the lurardous`mairn'she at as under Chapter 6.95 of the all non-point source regulations.
Cxlifamia Health&Safety Cade.Secdom 25505.25533 and 25534.1 undemand thv
if me trending d«s not currently have a tenant;that it is my responsibility to notify the
menpim of the rryuirtmen s which must be mei pct«to issuance of a Cemficale of
,. r,. Occupanry. r .
Signature of Applicant Date
Own)r«authonzW•gem Date j All roof coverings to be Class "B"or better
OFFICE
In