00090136 (2) CITY
I NUDODSONILLV OPERMIT CONTRACTOR INFORMATION:
HUILDINGADDRESS: PF,RMN NO.
OWNER'S NA. RT DR — . APPLICATION SUB DATE
919/21 /^
(HONG: KRI + 199 - SAN 69ZARQ AVE SANITARYNO. CONTROL NO.
O PHONE:
3 9 051 E BUILDING PERMIT INFO
z de PLDG ELECT PLUMB MECH
y te E r-�J o CI CJ
z 5 m= LICENSED CONTRACTOR'S DECLARATION Job Description
O z_,, I hereby a16rm that lam licensed under provisions of Chupler9(commencing P
t.,Hh, wish Section 7(xxp of Division Sof the Businasvn Prof•slo Gal.',anJmylicen.c '
s Y is in fall force and of t,
ds�u Liancec N — ADD A/C
de 3 a F Dam Common
ARCHITECT hot) e e DECLARATION -
t=�:O� 1 understand my plain skull be used m public me Ns
Is
'-z6fceo O Licensed Professional
de— Oot I..exempt uDECLARATION -
m— 1 hereby uffnn ohm 1 oro exempt tram the Commoner',cionsCas 1 taint Law fir the
Whosst?a which re reason(Seaton 7onstr t,sines and Professions CWe:Any city nr caumy
I x C which requires a permit reconstruct,alder,improve,Jemnlish,or rtpmr uny etmnam
e, prior to its isoance.also requires the applicant for such permit to file a signed summer,
that he is license,!pursuant m the movikilons of the Contractors License Inw(Chapter 9 S Ft. Floor Area
(commencing with Section 7000)of Division 3 of the Business and Professions Cafe) q aluation
or that he is exempt dtertfmm and the basis for the alleged mempoinn.Any violation
of Section 7031.5 by any applicant for a permitsubjects the applicant to a civil penalty OccupancyT pe
of not mare than ora hundred dollars($500). APN Number
13 1,as owner of the property.or my employees with wages as their sole cmnpema ion.
will but the walk.and the swcmre is not intended nr offered far sale(Sec.7(04,
Business and Professions Code:The Contractor's License Law docs not apply to an okired Inspections
owner of property Who builds it improves thereon,and who docs such work himself or through hes own emplayeos.provided that such improvem it,um not intended or
offered for sale.If,he%ever the Wilding or improvement issaid w;mmone year if 204 — UNDERFLOOR FRAME
completion.the owner-builder will have the burden if proving that he did not build or
improvererpammeafoon'). 301 — ROUGH PLUMBING
01.asowncr afohe Pmpeny,am exclusively ermmaning with l teemed comranorato 303 - ROUGH MECHANICAL
Lonswct the pontoon(Sec.7414,Business and Professions CWe:)The Contractor's
icense Law docs not apply m an evermore,property sone builds or improves therton, 304 — ROUGH ELECTRICAL
and vola,contracts for such protea with a commands)licensed parsuatn m the
Co505 — F I NRI_ ELECTRICAL
nteaor s Liceme Law.
❑I am exempt under sec. ,B&P C fee this reason 507 — FINAL PLUMBING
Owne Date
WORKER'S COMPENSATION DECLARATION 508 — FINAL MECHANICAL_
Iherebyatermorder penalty of perjury one or the billow ingdeclxmfons, 514 — FINAL PUBLIC WORKS
❑ 1 have and will.mainwin v Comificem or Consent to self-insure for Worker's
Compensation, as provided for by Section 3700 of the Lubar CWe, Iia the r
portae ace of the work ror which olds permit is issued.
LKhave and will mainuin Walker's Compensation Insurance,Lie required by Section
3701 of the Labor CWe,for the pe fournmee of the work for which his permit
/is
isolated.MX Wilke,Cam enseia ovulum rani r an,yi'idicy tp tyr,{.1L'[_L ..
Cartier._ Q 'miry No.: /f✓/(fL-�Z .
Cr
ALIGN FB%IiMI'PION OM W(ykKGRS'
COMPENSATION INSIJRANC17
(This section need not he mmplened If the rami,la for one hundrad dollars
($100)or lu.sd _
I ttdify that In the perkamunce of the work I'or which this pursuit is issued,1
skull not employ any Iwnnn in uny not set ns m hemnm.antero m the Workers'
Compensation Laws of Caliromia.Date '
Applicant ,
k NO[ICE TO APPLICAN'1:It,nperniking ohls Cenileate relEaenptina.tan ahauld
become subjectthe Wnder's Cme,saatlin I provimo u1'Ne labor Ose,you mint
Q p mfnnhwioh comply with such provisions or obis Permit shill be thvrmed resvknl,
z
E4 CONSTRUCTION LIiNDING AGENCY
I hereby affnn thw there is a torso atlimt lending agency 1111 the perlunnancc
ta7 or the work tion which this permit is issued(Sec.3097,Civ.C.)
[a Lender's Name
z LenJer'a Addrew
C.1 1 tend,that 1 have read this applu n e.and.nate thin the insist inl'nrnnninn Is
corn.I note to comply wish all city and enumy orliammes and and Iowa rtheing
L) at building consuvction,and hereby authnrim representatives of this city to enter upon
W the nbnve-mentioned pre penny far,mpe lion pta,awca.
rCw (We)agree to save,indemnify and keep harmless the City of Cupertino ugaimt
V1 liabilities,judgments,cots and expense which may in any way accrue against said
City in amstqu NDER thANDS Ag of this permit ��
SOURCANTUNDBRSTANDS AND WILL COMPLY WITH ALL NON POINT
SOURCE REGULATIONS. Issued by: Dale
Signature of ApplieaN/Contracmr Dole Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
0511 the applicant of future building occupant store or handle herholous material Type of Roof
as termal by the Cupertino Municipal Code.Chapter 9.12,and the London and Safety
Code,Section 2553200?
°Yet 13No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant nr future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection, 1 agree to remove
emit laza dous air cinuminants as defined by the Bay Arta Air Quality Management
Diatha" all new materials for inspection. Applicant understands and will comply with
°Yet ON.
all non-point source regulations.
1 have read the hrma daus materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505.25533 and,5534.1 undemmnd that
if the building does not currently have a tenant,that it is my mslamsibilay to notify the
Oecu ono of the rcquimmenos which must be d prem m isxuuneyinf a •dormant of
airy Signature of Applicant Date .
comer or authorized agent /� Ute All roof coverings to be Class"B" or better