01060021 (2) CITY OF CUPERTIINO
BUILDING DIVISION PERMIT CONTRACTOR'INFORMATION- "
BUILDING ADDRESS: PERMIT NO,
OWNER'S NAME: APPLICATION SUB DATE
PHONE: SAN ARYN CONTROL NO.
'44:5) 321 5599
p ZO ARCHITECTIENGINEER: BUILDING PERMIT LNFO
r_U F BLDG ELECT PLUMB MECH
aLIC
0 Z y 1 hereby offirmE[NatEDyCONTRAd under
DECLARATION Job Description
O z-e provisions of Chapter, (it mmenang
'te F w with Section]000)of Division J of me Business and Professions Code,antl my license
e x p st Lacers cl torte and y1 U
z r- Data
Class + Lt.# V
us
xoa� Date - commanr ' e INSTALL NEW CARRIER 3 TON �AIR
�CONDITIONER
n3 ns sM1all be u d blie records Y p
Cu�Tf � /Y
6 ii pe O Gce s Iona
w F,u OWNER-BUILDER DECLARATION
w thereby affirm that I am exempt from the Commuter's License Law for me
i o fallowing reason.(Section 7031.5,Bosoms,and Professions Code:Any city or county
se
- _
which requires a permit to cons[mc[,altar improve demolish,or repair any strvc[usometime
u, ci pit t it,' c 1requires, hesppf tf s ni,tt t
h peno file asigneds[a
a. mat he licensed pn ttothep 1, fm Controvior a License Law(Chapter s v _` . SL4Ft FloorArea(c gwiths t ]000)ofDivision3 of the B abdaandPrpfess,onsCode) _ - -. 19�yuati
on
or the[he,s exemp[therefrom and the luau,for the alleged eaemptich-Any violation
of Stairs 7031.5 by any applicant for a permit subjects me applicant to a civil penalty 5A�Ua���qi '
of not mole man five hundred dollazs(SN(Ko 1 J V Nunn
as i ':-, '<1; Occupancy Type
❑1, owner of mw326
e property,or my employees with wages as
their sole compensation. 13 0 2 1
will do me work,and the structure is not intended or offered for sale(Sec:7W:
Business said Professions Code:The Contresami s Lirrnse Law does not apply m an ❑ Sr � .
own of property Who builds imp tM1 cis and who does such work himself 203 - UNDERFLOU ls'lrl� :L
or through h' wit iadr,lciyocd.provided th t suchimprovers is ofintended 1
offeredfosale.-If,however.the building - rof .............. 3.0.3.'._.-ROUGH--MECHANICAL'... .._-,_.. ..... . .-._
or[mprovemem' old'm n dor y
completion,p e b sate,),
have mebuMenofprovngmathed'dnotbtildor 503 - FINAL MECHANICAL ENERGY -
uvp
improve far purpose f le).
... 508 - FINAL MECHANICAL -
❑1- er ofje p(S,c Y7 am exduvdy ommctivg Uode)ncotrs[ , t
i t [me p,.jet,(Sec Toa eosin d property&sslon Cal )Th C other or,
an cosh Law docs not apply to:m owner of acontrwho) Ids or improves thereon, --
duand.pUbmant to the.
" _C. r1msho L urs fora h p j ts.w th contractions)IBe&PCfor Ws;euon _----
C ba to L cense la '-
❑I tunderSee
. or WORKER'S COMPENSATION DECLARATION
APR (k 2002
Thereby affirm under pennhY;of pet Y fdm followingdeclarations: 1"I[ e7
❑ 1 have and will'maindin`a Ceriific5¢'of Cbnseni io'self-hrum for Worker'x ��®�ra.�
Compensation, a provided for by Section-3700-of me Labor'Codc: for the ry
artetm,ncrnrme work for wnien mm permh is iasum. .
��pyy��af the Labor
C to or:'he eCo pe to Inman i irciby Section
issuU of me Worse?,
Cal t the perfo, f me work for-which this permit s
issued,M iVo k Is,Compensation- C awd;P Icy b re
Y ^
Lamer �, . .,Ply N.,_W Iy�� ,� (]" ... .{ .. .... .-.. .. n ._
S
IFlCATION OF EXEMPTION FROM W RKERS I - v:i I"!
ri
-.(.- COMPENSATION.INSURANCE'_j,' - ------- .. ._....__.......
(Th ieaion need no[be cdmplerea ethe permit is for one hundred dollars < ,'l IAC" ;• d .,':,1 , I
(5100) I ess
I mfy N t er pert rma c f th ork f h h m P;4rt s s d I , r- •-"'
sh II [ ply 'Y P< Y a s to bccdm s bide[to the Workers
".... f _
Co.ph unit Laws f C l f m u:Di[c
Applicant .-.. . . :
aF
- - .._._.. -------
NOTICEOAPPLICANT. this Certificate afE 'Ysh1st
Z tiecomesusubject to.
fortthe Workers Compensation provisions of Latour Cayou mus[
'th comply Lim h provision' [h peonit shall bed ed mocked
O - -
CONSTRUCTION LENDING AGENCY
' �...._. _-
....
I h by aitch dirt permit
e e s con ova o leading
d'y as"
Y f r rhe peafowl nee' 1
4'— oRh rk for which m s p rtens'issu d(S .ipg7,Civ.C l
QLeder S Name. .. -....: ...:::........
Z
U I curl fY that I have toad this tipplictlam toadyism that he above irmism ttm is
I agree
to comply with all, '[Y�-anddrcounty ordinances and state laws-relating
to b
la(ngtoo lding construction,andhereby authorize rapmscmativesfrh city to [rupon
>s Wthe b [ property f p tp prp s
(W) [ofa dm'feke ph1s
'n. 1'ubl! flg t .ptheCity ofCpeti
ynnY a agaatsaid
City in ongefmg m a fd
Ns NIMPLY WALL NON1. -POI
oLRCE R6 Vl
Issued by: TO /V70 r �(� a/_
Date
APPLICANT UNOE O
S Dr
S,g t
App canr/Connac[or pale T
HAZARDOUS MATERIALS DISCLOSURE `>,! Re-roofs
II rhapplic t 1 t bathing p t t,e or handl n'mardi melodist -Type of Roof•.
as defined by the Cupertno hl idcipxl'C d Chapter 9.1 .,sand the Health and Safely -
code.Section 25532b" - :
1 1 U r
ii
°Yr __All roofs shall be inspected.pnor.to.any roofing.matenal.being installed.1--r.
• 0/dl m pp`o ummus, bold g ` eq pine r device,which If a roof Is installed'without first obtaining an inspection;I'agree`to remove
emit sod t [s as dcfn db theByArcaA Q It Management o
_all new,materials,for,inspection.,..Applicant-understands and will comply with-
❑Y< all non-point source regulation
Ih ad�th
notorious
Ifm M1zad . mei 1q -¢v dCh p he un lm Safety Cotl S ton b>0h 533 and 25534I '16.95nd[htbu dn d , ot<u
ly
_
which - responsibility -._.-.. - .. --.._ ... .....- _
occupant r the redo a[ t [h t [ srico m< • „ / C - ......._
en¢ huh m�tbemt [ f Ceinfi ate of
Oc l nc�. p .. .- . ._
„may, S re of Applicant 1 Date
[
t 'owat,erznm � All roof coverings to be Class "B"or'.better
or zed g m 'Date .
-.. . __ ._(. -OFFICE ---.-...__ .. _ . . .. . .... .. . . . . . ..-.... .....