00090175 (2) CITY OF CUPERTINO
BUILDING mVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PI:RMI'INO"BURYCT .
A PERFECT TE 000901.75
OWNER'S NAME: 521- KIP*rAPPLICATION SUIT DATE
-N 09/27/2000
PHONE ' SANIFARY NO CONTROL NO.
C1O ZO ARCIII RCrIE,NGINEER: BUILDING PERMIT INFO
m❑ BLDG ELECT PLUMB MECII
FEW IJ 1=1 1.I I'-1
vOi� LICENSED CONTRACT OR'S DECLARATION
ON
y5 Ihereby infirm, lam licensed timer provisions at Chapter 9 larmnuning Job Description
�mCu with Section 7000).fDivision3 ofdw Business and Pmfeasions Code,mood my license
2— is in full force and e
al'ce W Li,cr.er.ILs Lie.. FURNACE CHANGE OUT/ADD A/C
O O
ontract",�ARCIFEC I"CpLc_P9RNDim
e.O 1undcemnd my plans beused
uspublic records
-
za�}I /
Licensed
sx G OWNER—BUILDER DI CI SRAI'[ON O
Ili I hemby.(S or I pt In , theC t m f - la ronhe
f11
C/0 (o g (S 7111 S cf : ly e
I - C : y ' nc
ASO w1iJ pm+it, -I t hu, p J I:b repair Y-ImUanere
i 3C3 prior t t aW rey p inion t f uch amemse l f l s eJ ante nem
mane I w ap Section
n p ons lith c r Inco, � on,Cor9 Sq. Fl. Floor Area O Valuation
(comm enc ingwith Seainncial and Division eof the[,,adc and Profession.Cmc)
x Se t he is exempt therefrom and tic basis lirt the alleged ememot Any violation $1,
of Section 911?LS iv any nppllcnnt Iia a pemnit subjects me applleunt m t civil penalty
mn,olm"rt�a,nn eve l,aa,aam donarn(Ssta)I, � APN Number - Occupancy Type
❑1,as owne,nI the property,or tar cntplest with uagev as their%mc conTemadon. 13 6,7_.53 IP
Is d ill do the work,and the structure is not intend or offered for rule(Sec.7(I .
Business and Professions cede:The Con,racmr's License law does not apply to an J Required Inspections
wcaner of property who builds or improves thereon.and who does such work himself'
-thmughnisowncmmloree..Erideen,a,xact,a,pm.-.,mem.annn,intendedor 204 — UNDERFLOOR FRAME
(offered fu vada.II;n"weveq the huddleµor improvcmant Is sold wilbin one yea,or
mndotim,,me(owoe.-rime,will have lie burden ifPosing ma,hedid mor build... 301. — ROUGH PLUMBING
mpruve tar napo,e or 4c.).
01.us owner of the property.am exclusively cmntruning with licensed contractors m 303 — ROUGH MECHANICAL
construct the project(See 70144.Business and Professions Cmc"The commmors 304 — ROUGH ELECTRICAL
iceme Law doe,tintapply to an,,tune,of property wno builds n,improve,IIIand ono emmfrwl,Ire'.till, pr(gee,,win,a a+m.unns)bemused is an m the 505 — FINAL ELECTRICAL
comma ors Lasers,Law. '
❑I.m eacmpt under See ,R e,P C for this mason 507 — FINAL PLUMBING
Owner Date ' 508 — FINAL MECHANICAL
WOR K12 R'S COM PENSAI'ION DECLARAT ION 914 — FINAL PUBLIC WORKS
I It,cry aB ort ander penally of per lnry one of the lidlmwing dcc lnrati"ns:
❑ I have and will maintain a CcAhcme nr Consent a,wl6imum for W..ker's
Compensation, as provided for by Section PW of the Lahti Code, for the
performance or the work torr which this permit is i.med.
❑I have amid will malnhdo Worker's Cumpcasanon Inwrame,ns required by Section
3700 ol'me Labor Code,lo,the pc,Rm"an,c of the work fir which this Nrim Is
sued.My./Worker'%CCianpemation Insurance carrierand
.Policy number arc:
Cartier_)9( &%,a OF
CERTIFICATION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE '
('I'hh section need not he completed it The perinit is for enc hundred dollars
f$IIIOI or leas.) •
1 certify that in the perforrnance of the work for which this permit is issued.
shall not employ any person in any manner so as to become subject to the Workers
C(omfer"eion Laws of CaRl'um'.Date
Applicant
NffricE TO APPLICAN'n It,after making(hi,Ccnilicatc"f Excmpne,,you should
bcron
me subject ,the ovol er .m
',Cnmpcntion provisions of the Lxlwr Come,you must
Q O forthwith comply with such provisions or this North%bull he deemed milked.
F r^ CONSTRUC`HON LENDING AGENCY
1 herohy mTmt that there Is a conwue,"n lending agency for the pmfomnance
of the work for which his pernh Is issued ISI:.3097,Civ,C.)
L Q Lende,'x Nmme .
7 Tendo',Address ,
U (z I certify mat l have mad this application and state that the above information i,
4. p correct.1 agree to emnply with all city and county ordinances and stare laws relining
C f, ,,building cnndmctloa.and hemhy a ohod,repm,mamiviceol'this city to enter Ilam
the above-mentioned property for inspection purposes.
Cl. IWe)agree R,save indemnify and keep harmless the City of Cupenmo agmmi
I liabilities,judgments,costs and expcmcv whichmay m any way re against.,id
U L City in con" ice of the granting of this per u.I. (�
APPLICANT UNDERSTANDS AND WILL COMPLY WRIT ALL NON-POINIr Issued by: �' Date 2' .—�
SOUR LATC)NS, pn/��a
Signatnrc at A,j li aal/Yak+nuaanr +um Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the apphcanl or future building occupant store or handle hermin nos,material Type of Roof
as defined by the Cuperma Municipal Cedc,Chapter 9.12.and the Health and Safety
Cm,Section 2553260? No
Cj Yes El All roofs shall be inspected prior to any roofing material being installed.
Will meappliaante,rhammh,addingniecepm„1^1afo;plawalord."ce'111,ah If a roof is installed without first obtaining an inspection, 1 agree to'remove
anal Imitations air conunninunf:as defined by fhc Hay Area Air Quality Munngcmen,
District! all new materials for inspection. Applicant understands and will comply with
0 Yes 0N" all non-point source regulations.
I have,cud the hmxNom mme,uls myniremenu under Chapter 6,95 mf the
CallforNm Health X Safety Cndu.Sceions 255115,25533and 25534,1 undcdtand that
it the hadding does not cummnly hum a lenunI lWn it la my m,ol,ihility nattily the
D'cupunt of the requirements which must be met prior to violinist,of a Ceniticum of
°a°ap� Signature of Applicant Date
owr o
nar aa,,o.ized agentIan;ae All roof coverings to be Class "B"or better