01020050 (2) crfSI
PION O
BUILDING V
PERMIT CONTRACTOR INFORMATION:
IIUI�l )f�_SS: N ` PHRMrl'N(I.
((// c� � 0
OWNER'S NAME: ti, 1� APPLICATION SUN])At 17.
v Do,� 3yy9
1'II(INE: .�_ ,/ //'/ tiANll'AHY NO. COVE Md.NO.
pzy° AHCHITIiLT/ENGINEIiR: J` ✓\v/ BUILDING PI7HM111T INFO
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251 ,59 e.," FILING /ELECT PLUKIH MEC.
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Sy LICpNSEDCUNTHarae,S DELLARA'1lON Job Description
y l2 G hereby afpfna slim not licnt.vnd under prnvinionx nl'Chup,cr ,9(urmme etng
F, ae will Seetion700mol Uivlunn9uf the Business nn Ynafex,iun,CodrI.m1myllcen,u -
a�Y ie In lull Ione and ellacl.
Oi U Liccnve Claus Lic.M
F LL a.O DJIC cJnlnl m_— /'< ��" //`U J /� / �L O We
to 3n ARCIIITECr'S DECLAR I O I//.IJ)p
1 understand my plans,hull servitors public V.
Licensed Profesxi.nm
n er OWNFR�HUILDER DECLARATION f
or 1 hereby affirm,hal 1 ant exempt front the cur m"ll, License Law Ern the
toll—in,omom.(Section 7031.5.Buoine,,tend Pn I ..was Code:Any city oetn its
dO w1'ul y 1 II , , II 4' Init, p;' ) num, -
er prnn , I. the PPI' ' tf 'uhf lull b d.ltnenl _
hot he licensed perwa ,t n pmv5tin, nn C tracho,L Law Chopterv. Sy. Ft. Floor Area Valuation
(commencing with Section 7000)of Unusual 3 of rho Holmes,and Poefeu,lnn,Code)
or that he is exempt rhendum.and the basis for the alleged exemption.Any violation
of Section 7031.5 by any applteam few u permil subjects the applicant m a civil penally
Of not mom than five hundred dollars.(5500). APN Number Occupancy Type
❑1,to Owner of the IF...mny,or my employees with wages as their sole compensation.
will Jo The work,and the,Imaure is not intended nr offilood for at,(pee.7,W4,
nm nm,and Pram„brit,cane rlie Ca traces,.Liecsw Law all,oat apply t.an Required Inspections
w Ill rosary Wilt,builds or ill.sded t tecrcn. tmA win dna.,uch wink intended
rr ncr Ill his awn crop...Id,,prrvldM, li-such II I um,um nm Intended n
amend for sale.If,however.tee building Or hnpro,c n s sold within ane year of
repletion.the owner huilder will have the burden'up Ing Rod he did nal build nr
mproveforpurpose ofrole). v
❑Las ownerr of f the pmpeny,am 414.Business
d Ispo ling who licensedcontractorsconemts cit
nxtr, the Pes.,ISa. ,, ,Nosiness mWeny.his
Cnlc)File contractor thilmo. j
Ind wh co Joe,nm apply to an ownet tel propertyemo hu1In,Or seimproves Ncmm. S
and who r,Livens fnr inch Projmv with a unmrvcmdxl loomed pursuant m the O
01co,tore p,mile Law.
❑I mm cx.mm roma.sa. ,n&PC for this rees.m
Owner Dane .
WORKER'%COMPENSATION DECLAHAI'ION -
1 hereby affirm under penally of pe Jury one of the following declarations:
O 1 have and will maintain a CeniGcae of Conserv ,,w1binwre for Worker',
Compensation. as provided for by Section 3700 Of rhe Lana Crtda for the
,anonance of the ,,,it for which Ill,,Not is issued.
❑I Inns and will nauin on W..let's C.ntpcnxatinn In.u..nce,an required by Section
39(1(1 of the Folio,Colu,for rho Iw,fonnuncc or the work fnr which this permil I,x
isvucal,My W`o/rker's CC i,xno sun Invurmce currier and ' l..yl ler am' /
Cornier: ✓ Ti ` Policy No.: L � �t^� s
CERTIFICA'I[ON OF EXEMPTION IBIJM WORKERS'
COMPISNSATION INSURANCE
('Ibis section need not be compacted lithe permil is torone hundred Jnllun r
(51011 oT less.)
I croify Ill.,in Iha perlo...it ec of,hc work for wbull this purmit i,issued,I
,hull n l employ uny person in any nanmer so us it,bcannre subject er the Worker,'
Cotnpct mlion Laws of Culifnmlu.Dat,
Afpllcnnl -
N(YI'ICE To APPLICANT':ll,alternations,his Ccrtiticmc of P earful...you should
Z
become objectm,he K'nrker',Compensation pro ism of,bel.abor Code.you must
O lonlwi,h comply with pre,such .ton,or this permit shall be deaned revoked.
z O
E” Cf INYI'RUM ION LENDING AGENCY
1 lereby of ion but Nem is a r.mmalion lending agency for fine perform oro
Of the work for which his permil is i„ucd(Sas 3197.Civ.C)
6t Q lander',Name
a, z Lenders',Address
V O I cenlfy lha,I love mad thus applicml.m and sal.,hat Nm move lnromwlimt ix
ormm 1 a,.rot comply ,uh all city and cuunly onlinances and lame Imes rclming
O U ar building construction.unit hereby authorize mpwertualsex of dirci,y menmrulum
y tzl the abese-motioned property for inspection purposes.
(We)agree to me.indemnify and keep hamtless he Cilynf Cupertino against
N liabilities,judgme n,ttnrn and expenses which nay in any say atnme against said
fly
mro .2—,�
V z Cnxccoyu c fi�he,mbir,of this permil.
APPLICANT ' s TAN DSANDWILLCOMPIITH ALL NON-MINT Issued by: Date
SOURCE GULA IN'' 2_-
/lJJ Y
Sigma car Al,hcamJcnn,memr Oar Re-roofs
IIAZARUf n)S ATERMLS DIl HH
Will NelWhem mr,n.am aldhrgaeepam.mnm.;handle homed.m,ntmenal 'type of Roof .
as declined by the Cape, n Muni pal Code,Chapter 0.13.and the Health and Solely
Cale,Section 25532(,)1
0Y" ON. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant nr future building...,all,use eyuifinem nr devim,w hich If a roof is installed without first obtaining an inspection. I agree to remove
ani,haewduus air cmnantinam,to defined by Ilse Ilay Arta Air Quality Mkol,emcnl
D"hiav all new materials for inspection. Applicant understands and will comply with
0Yes 0 N all non-point source regulations.
Ibaso read me Itunardn„x nrocdnl,remM1tunanu,coder chapter 695 of ore
Calif m!,Ile,lth&Sm'cy Code,Section,2550.5,25533 and 25534.1 un ici stand thin
It the heildiny does.,,it aurmmly hive.mmmm.thus a is try re,p.nsibi lily t.utility the -
ocwncr
m mmmxos wlich nom mm ....r m u,mancc of a Certdwrlc ul'
O
2-12-01 Signature of Applicant Date
mnad,gen— Dare All roof coverings to be Class `B"or better
OFFICE