04080233 (3) CITY OF CUPERTINO -,,� * 7A. 77 '
4" r^
BUILDING DIVISION PRR .,CONTRACTOR INP ON
BUILDING ADDRESS: PERMIT N'04080233
004080233
:�it
NER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY O. CONTROL NO.
CHTPECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
00LICENSED CONTRACTVR'SDECLARATION Job Description
lose affirm that 1 am lisnscd under pr s of Chapter 9(commencing
Sc ").r Division3ofthc Busimalls Pmfcasiuns COde.aedmy Rcenects
in run rake and wr&c1,p, �'� DEMO (E) POOL
^ i Licen CI Lic.p ~LED�oDaleS= g .gT�caatamr CONTRACTOR: DIRTWORK (zF777}�7aN\lrll�
ARCHITECTS DECLARAT f
�i P I understand my plans shall be used as public mcnNs V`h l
P
n
'o G Licensed Pmfessianal k c _ J . 2004
S OWNER-BUILDER DECLARATION v_.
l/ c7
'�<f1 herehy a firm'hot 1 am exempt fru.Ne Canwetm's License Law for the
p o following reason.Pencil
t ](13 L5. t,Business and Profcaimli Code:Any city or county
ctur,
S..20
m which requires a permit to UirM Be allee improve,demolish.fi repair any xuument
pilar.is lensed s.about PUMUantquithe ponvisions of forsuch Contermitmicensfile ae Law(Chapter
,
Un
that he isliccnssJpursmnumhepmvrsinvnrtheConwcmr'xLittnsslawlChapter9 Sq.Ft. Floor Area f�r 200
z�m (commencing with Section 7")of Division J of me Business and ProfeainnsCnde)or
Us $ Wt he u an mpt therefrom and the bases for the alleged sorption.Any=of
Section 7031.5 by any applicant for a permit ubjects Be applicant o a civil penalty of APN Number Occupancy Type
not more than rave hundred dollars($500).
I]I,a owner of the reform,car my employees with wages ax their sole comperwdon, 35701053 . 00
will do the work and the structure is notimmmded or offered forsalc(Sm.TOW,Bar. Required Ins ections
and Professions Code:The Conua.ots License,Law docs not apply to an owner of q p
property who builds or improves thereon.and who does such work himself or thmugh his
own croployess,provided that uch impmvemenu are not intended or offered forms.It,
hpwevcn Be building or improve eat is to ahmoroyearofcomPletlon,deowner-
'builder will have he burden of proving that he did not Wild or improve for putpme of
axle.).
❑I,as owner of the Iranian,am eaclusively contracting with littnsed conuacmra to
construct Ne pmjcci(See.7044,Business and Professions Cade:)The Convector's Li.
nm law docs not apply'.an owner of propcny who builds car improves thereon,and
who contracts for such projects with a eomnemr(s)licensed pursuant m rhe Conuscmr's
License taw.
I am ceempsunder Sea .B k P C for this mason
Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a CevlBeamof Conant to self-insum rat Worker's Condon.
motion,m pmvidcd fm by Section 3700 of Ule Labor Code,for she performanm of rhe
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insuran¢,as required by Section
J]00 of the labor Calc.fa Ne petfomnance of the��/w�r�1a�.reckk fff/orwhich this permit is issued.
My W�fJcgh Ck ERTca'i. EU $MPI sON?ROMaWOR be-1LQ2�
�J COMPENSATION INSURANCE
(This auction need not he completed i(the permit iaforane hundred dollars(Sial)
A,least.)
1 certify Nat in the ferforman¢of the work for which this permit is issued.I shall nut
employ any person in any manner m as in I Cco.e aubjcm to the Workers'Componsauon
Laws or California.Dale
Applicant
NOTICE TO APPLICANT:If,after making this Cenifcale or Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
.J'Z fonhwith comply with such prmisionscar this permit shall he deemed msCkcd,
ZO - CONSTRUCTION LENDING AGENCY
[�."' I hereby affirm that there is a construction lending agency for We perrurmance of
pv. the work rut which this permit is issued(Sec.]W],Civ.C.)
14] Q
Lcriblims Name
� z Leader.
U C) I minify that i have mad this application and stow that the above informatiun is
fl.F correct.I agree to comply with all city and county on inanom and mile laws miming to
OU building.ammucuina,and hereby mthmve.pmacnu'ivm of thiseity m enter Orion
on e
Uabove-mentiuvcd rmpeny(Or inspcclan Purposes. I
CL (We)agree to save,mdcmniry and keep harmless the City of Cup ld .,ain't
fq liabilities.judgments.costs and expenses which may in any way eccme against said City
U Z, in consequence of the grantinga('his perm it.
APPLICA UyP$RST NDS A COMPLY WITH ALL NON-POINT Issued by: D�
/ �OV E e CATION
%�i�� - 1G" Re-roofs
Signawreof Applicant/ omnaor Data /
AZARDO MAT ALS DISCLOSURE Type of Roof /
Will the app item or ruwr Iii cupandsmm or handle hanrdous material
as defined by IM Cupertino Municipal e.Cbapncr 9.11 and the Health and Safety
'ode,Sermon 25532001 All roofs shall be inspected prior to any roofing material being installed.
❑rem la a
future building use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant orf
tout W.Ahrms air conmoirsm.ss defined by the Bay Aaa Air Quality Mmagcment all new materials for inspection.
District?
0Yes No
Ihmv n,adlhehsnNrmsm riabrequim=ntsundcrChapwr6.95ofd¢Caliror-
AkiHnithdtSaEtyCadc,Sccdonsl55�255335534.1 understand tha'if the building
docs not Canenlly m a run the iihllity'n Anil,theoccupant of the
araccdhcamaroc c Signature of Applicant Date
c�
net it,aathomad a, t Date All roof coverings to be Class"B" or better
� I
OFRCE
COPY
REC
AU4 8 �Q94 � a
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C;jv 0f pRi1Vl� - v
81111 1� RPPROV d
.111 AMOM E WITH rue CITY OF
ES
StCiIEO
\ Th of p t apse fications MUS
be the bb e< ad ti and itis un _
Iavd1j to make any change r a era tam
(M ftta wdheut written germission frorr. c ��
tg Dept., City of upertino.
i pNng of this Nan or d specifications r
I t. NOT be held to pert lit or to be ar. 1
Mal of the violation of any provtamn• O
r av rin- ft Amance or )T to Lew Q
a
CITY OF CUPERTINO
DEMO o v Z 3 3
CUPE(�TINO PERMIT APPLICATION FORM
APN# 2S-7 01
OS Date: a
Building Address:
Owae�is Name: Phone#: j
No�VO,.A Nsw Skog- yuiA o3 l
Contractor: License#:
l
Contact: Phone#:
Applicant/Contractor:
���CQ, Sa.vJa`I'tJ•d.. �J,\ IV17v{� V1h��rJlif'e'�
Building Permit Info:
Bldg Elect Plumb Mech
Job Descriptio
Residential: �)t7 Vt �em v Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuatio
. Type of Construction:- Occupancy 6 up- r
Qt . if
A l abl Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
BSEISMICRE Seismic Residential BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
# �16Q 't
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