01070090 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21772 LINDY LN LOPES ELECTRIC INC 01070s0�90
D\ NANf6SE WATER CO. 1060 ELM ST APp"I T�D�vsyY661
PHONE: SANITARY NOO.� L U CONTROL NO.
(408) 984-8422
g Q ARCHITECrIGNGINEER: BUILDING PERMIT INFO
kL" BLDG ELECT PLUMB MECH
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LICENSED for CONTRACTOR DECLARATION Description
1 nercb aR that I am licensed under revisions of Cha rer9(commencing s,�oobb
of=o y " " g INSTALL ATS & RECE
pm�u S section7o00)of Divizion3 oftM Businen and Professions Code,and my license
<xy is in full force and eO ZsZ
d o se License Class Z) Lic.n
Date S DEC for FINALE D
LL O -ARCHITECTlloruse UECLAft T
fund
underxtunJ y plum shall W coral as goalie record,
ad
o o Licensed P,nfe„ioml JUL 2 6 2001
K o OWNER BUILDER DECLARATION
y m 1 hereby ff Pill I pl firm,the C t a: Lcc e 1 rtr the
toll n, (s 703 1.- lmxaacdl f_ Code Av city,ar court) $9000
LSO which y Permit r t .11r ' p cJ Iso I.- ya'ucmre Bvl�
i3 _Pnormits issuance,also rcqu rcsNmppl cum for such pemdt mfleangneJsmmmem - -
IhaheistiecniediwrwarunNc pmvix.m.fthe Cootmctoe,lacenae Loach.pmr9 _ 3 e rYpsyaj% If• Valuation
with Sodium 7”)of Division 3 of the Business and Professions C ), -_1 - f.�.,E r ..
or that he is exempt therefrom rand the basis for the alleged exbmpri co Any violation
of Section 0031.5 by any applicant for a permit subjects the applicant o a civil penalty
of nor mom Nan five hundred dollars(S5W). 304AP-N h$QAWE ELECTRIAL " Occupancy Type
°I.as owner oftheproperty or myemployees wiin wages as their sale compensation. 501 — FINAL ELECTRI AL ENERGY
will do the work,and Profession,
suuaurc is not intended oreofferedLaw for sale apply to an 505 - FINAL El�fl'�'r$fZXB�ctions .
ownBioer
of and sorry Who
Cusbuilds
o The Contractor's License Law s such
not apply m an
of h his own
Who builds or improves t at such,and who docs such work himself
mNrough his own employe<th building
In.,such improvements are not one dedyear or
,offered for rale.If,however,the building m burden anent n sthat hetdid one build of -
completion,purpose
ofbuilds will have the burden of proving that he did not build m
improve for puryose of tale.), :
-us owner of N<propors,tor exchniNdy oat _ s th licensed contractors to
_. _- . . . _ ... ..... .. __ . .. _ _ _._ _ .....
racting
_ License
the does
n (S¢, to a Butlers and Professions ildo:)The Improves
Contractor
Lice who
Inw does not apply m an owner w of progeny who Wills seimproves thio the
.�� and who comrocts for.such.prolae with a contractors)licensed pursuant to the
Contractor'sexLicense LLawCIa
- 1 am csemD,under See. .B&P C for this reason
o her Date
WORKER'S COMPENSATION DECLARATION
_ 1 hereby affirm male,penalty of perjury nne of Or fallowing declarations
O I have and will m:mum a Carnfeat< of Convent m self-insure for Worker',
Compensation, as,provided for by Section 37W of the La W, Cale, fur the
performance of the work for which Ills permit is issued,
°1 have and will maintain Worker's Compensation Insurance,as required by Section
37W of he Labor Cale,for the performance of the work for which his permit is
issued W rkcr cf�S.:henvttiorh lnwmnee carrier and Policy number
_ �;J TC _ - ...
a6ia:� ' + .• Policy Na: W LX LI' In 20'('d ;_t .ya,. t, ,r, f % . 1��•x
'• FICA N OFEXEMPTION FROM WORKERS'; - --
COMPENSATION INSURANCE_,' "" -
nDo,section need not W completed Hthe permit is formic hundred dollars
(SIM)or lura)
certify that aided performance o1 the work for which this t e issued I r ..
shall not employ any Person in any mammy w as it)become subject
c,to m the Workers
compensation huw.t°f Calif°miu.Dom
Applicant
NOfICE TO APPLICANT:If.afar making this Ccm r, fof Exemption,you should
Z Wchavoll jenmthesuchitC°mpemr its peram,shot fill, C,ckod. must
O O forthwith comply with such provisions or tai,permit shall be teemed revoked.
P ^ _ `CONSTRUCTION LENDING AGENCY
' 1 hereby aRrm that there is a construction lending agency for the performance
f11of the work for which this .it is issued(See.3097.Civ.C.)
a.Q Lender's Name' - .
Z Lender's Address
V 0 1 cenify that I have read this application and state that the above information is
kn [r correct I agree m comply with all city and county ordinances and stats lawn relating
O f..) m building construction,and hereby aomoriee representative%of Nit city in error upon
;w gat] me:m°ve-meavoned property a.\
y tot Inspection pumes.
.F. :. (We)agree m save:indemnify and koep hamlets e City or Cupertino against
rn lirabiliocs.julgmcnta.vests and cxpcnas.whlch may way accrue against said
U Z City in armeyuince of the graining nt this t.
APPLICANT UNDERSTAND. ND W' C LY TH ALL NON-POINT Issued by: Date
SOURCE REGULATIO' Y'
$ign5wrt of Applic HACARDOU$A .VERIAIS DISCLOSURE Re-roofs �� eggs
Willthe applicant or mtyrCWilding occupant store m handle haaaNws mu¢rial Type ofRoof
as thi by the Cupertino Municipal Cale.Chapter 9.12,and the Health and Safety
Code.Section 25532(x4
°Ya• °No -All roofs shall be inspected..prior to any.roofingmaterialbeing installed..
Will thea Meant or lumre buildin mcuaant usec tmrde.ices which v t
pp g, 1 gmipmen If a roof is installed first obtaining an inspec[idri' doree'to remove
mit hazardous air amtamin:mt%as defined by the Bay Area Air Quaip Management
Drtrdar^. all new materials for inspection. Applicant understands and will comply with
t°Yet °Nn all non-point source regulations.
I have read the haamdous materials requiremmu under Chapter 6.95 of the
C.'tomis Health or Safety CWe.sections . 5.25533 and 2553y.1 understand that _
!if mbuildingdoo,moou shave. n tNatit is my msponsibili,y,o notify,he
capon,ofthe me which met poor m issuance of a C<niflam u(
captaincy. — Signature of Applicant, ., Date
morn n-aa8 ate All roof coverings to be Class"B"or better
OFFICE