01010060 (2) CITY OF CUPERTINO '
IMILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDINGADDRIiSS'. _
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OWNER'SNAhe /SPPtFEa} f��tl SUR DAIS
DIE (4101 I'll I.I.CI.A„ (:4 5 110`4,111,1137 ST
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PITON@ (408)27E1-0330 SANITARY NO. CONTROL NO.
p z Z ARCIII'I'IiC'I'/IiNGiNElilt:
BUILDING PERMIT INFO
�to BLDG RLECIPLUMB MUCH
ad�� LUI 1=1 IJ I=7
zI.ICI:NSEDCONTRACFOR'SDItCLARATR)N Job Description
o z—❑ 1 hereby aroma mal 1 am licensed ander provisions of Clupe,9(c„Innen ine
pmCw fall
alto!Divi.ion3nfdm Ruxinesaund l'racviona colo.anAmylictmc II c
x s
is m lilt free and m eel. NEAP"t C11 1' C7 IWCIOD, Ihl'AL..L7./r f�L..Y f DX
_ s i.ireme f las. e(`3_'t— Lie.p y z/o $
's°LL� Dale_/_/?=o-tCnnwelnr_�j.� — TIxl.5'TAL-L.. 40 YF::. C� f�71 Ip SI LT.NCA_If'
ARCIIITELTS DECLARAI or _
I wdcr.mnJ Ing pinnx nLnll healed a.public;ecnnh
a4 7
Licensed Prolcxxion;J
n S 1 z OWNER-BUILDI!R DI!CLARATION
a. I Lerch,mlirm Iia,I um ucmpl Lea;the Contractor's-License Law for,he
I—_Z following a earn.slansin](131.5.Business and Professions C Ic:Any city or county
O which rap,ires a permil ro construct,their,humor,Jumolish,lar"air any strums,,
i
Wm prior a,is issuance.also require.,the applicant lot such permit m,file a signed nmcment
m:..he ix lie...ed puruam I, Ile nawiau;is rme Committal License Low,p7hapier 9 Sq. Ft. Floor Area Valuation
(commencing with Section]IMIU)(il'Divi siren 3 of the tlu,inc.v.l red PrnRSsions Code)
or that lots exempt,bcr4mm middle basis go the alleged exemptionAny vi.lminn
or Sa,ion]III 1.5 by any applicant on a permit Subjects the Tpllcam a,a Civil prorly ,a-
ofnotmo,ethan rise hundred donat.a5au. APN Number - Occupancy Type
❑I.as owner of the pmemployees
pcn%,n my with wages as their sole compen;ulion.
will Jt,ane work.;,,ill l e.;ache is.o,i,gonded or Oared for sale(Seo.7044, - Required Inspections,
Business and Pnde%dom Calle The Comnaclar's License Low case,not apply to an y _
own,rot gingery Who hold., n:Pru ca Neeson,and who Jae,such walk himself
m through his own ennployms.provided,hat such innproce,nenl,arc no,intended or
offend for sale.B:h.wner. he h,:ildins or hnpmvemem is sold within one year of 30:Pi G"hYll'IE':
completion.the owner.huRder will base the burden of proving sun,he did sun torld o;
mpraleforpurpownfsalcJ, ;E)7 '— :[h&.1LA'1'I(:IN
❑I,as owner of the propene,am exew.ively contracting with licensed contactor,. 601. — R(:U]F' '1'E M
L,nstruct he pl(Sec.]tut Business land P..lc,,io;rex Cote:)'Ihe romr,,nors
icense Lw Joe,not apply to an owner or pmpenv wroo build,ser i;upmve,mercon. E'02. — Fi(]OF' 1::7—YWOOD I,IAIL
and who conum,l, Pa snch pmjncln with "Cnmr'anorlxl liacnad punnam to Ile
Comaemrs Illustrate Law. 603 -” Pd]CU= h1tf1T PENIS
❑1 an,exempt antler Sec. .B&1'C for this reason
604 -- rvnF 114-rROM0%
Owner Dam
WORKER'S COMPENSATION DUCLARAI'[ON
1 moth,"!firm under penally of perjury one of the r.Ilowin,dcclumlon.0
O 1 hast and will hminmin a Cenilwalc at Clausen' In sellnin,nrc Ibr Wnrlar'.I
Compensation. ax pminded far by Section 3700 of the Lads Cale, for the
perform:,nee of the work bar shwh,hlx anal Ix issued.
ID I have and will maintain Worker's Clurpen,a,ion Insurance.its required by Section
37M of the Labor Cale,lin,he peinsurance.1,he work Ibr which this permil ie
Issued.My Wnr1'r'x Cnmpensmi.i Insurance carti'v1 and policy number are:
Carrirc. t14.Ce_lU[)Ir Iii IiMin ic 1'NIir:ON�'RO �t NKI �S"� I
CUR FIFICA1]OCOMPENSAI]ON INSURANCE
This section need not M eomplerad if the permit is for am hundred dollars
is Tall ar Inn)
I certify Iha,in the perfnounce of the work Bal which,his Icrunit i,issued,I
.hall not employ any Peron in any manner u,a,to become subject to the Worker:
Com,n n.io.Lows orcmiro,nia.Dale
Applicant
NOTICE*10 APPLICANT:If,after making this Cerificate of Exemption,you should
came subject the Worker's C.... xminn provision,0 he Labor Cda Yost must
Q O M
fort nand,with srich pn visiu.,on his permit shall be deemed revoked.
H ^
CONS I-RUCTION LENDI NO AGENCY
.� I hereby notwhich this there permit is
issued(Sion 097.leadingagency.) lirz,he pcvfarn;unac
0. of the work for which Ni.permit is i.emd(stt.JfH],Civ.C.1
6. Q L<nder' Marc
Z Lcndcr's Address
V C 1 cenify that I hoe read this application and state that the"once intentional final i.s _
LLI [r c voce I ug,,I mply with;ill city and esnmy oNirmse,and xlate law.relining
Q U to building construction.and hereby amluniae reptescma,ive,of this city to enter upon
y he alawomr,nional pr„pray rur.op mon arross".
l.. a (We)nine.to...I,ialmnnify"red keep Lannles%the Chyol Cul,cmn"again.,
Zi liabilities,indguams,costs and expenses which Buy in any nay accrue against said /
U G City inconsequence of the granting rel'Nis permil.
APPLICA ONCE STA Issued by: Date
SOURC EGDLA'I'IONal
S/I /.../ �_tT / y'
sgn,uw ed Apphcaoua�mr.;nor ( Dare Re-roofs
UAZARWUS MATERIALS DISCLOSURH
Will ne;,ppr.:mtInLure building a=up.mthan,orhandle haanmans,nmcrial Type of Roof
as defined hY me C.,mno Municipal Cole.Civapmr 9.12.and the Death and sale,,
Calc.Saline 1553]1)7
oyes k.I, All roofs shall be inspected prior to any roofing material being installed.
Will he u,nlicam orNlm hufiaing occupant use egni,mem it ill which If a roof is installed without first obtaining an inspection, 1 agree to remove
.all M1aenNnu.Bir cunn,;ninam..xx JelineJ hY me NaY Arca Air Guali,y Management
Dian., all new materials for inspection. Applicant understands and will comply with
0\'`^ all non-point urc regulations. //
I have real,he h'Y uNnus materials rey.irmacm nh,2.550,5,25533 a under Chapter est 0l'me ---� / �--
Tabl'orniuingdi &mulctentlle.ave,ateant.thtitisam %pram,. undcumndNm /7-0
i"'n building curtemlyhoca tenant.that itismYssuanceofa' enmily me r
�' Pam m Nc ra n which must he mut prior m issuance of a Cenificnm of _
°""p `5'' (� L Signature of Applicant Date
owner ,rinmodaed,Igen, Date All roof coverings to be Class "B" or better
OFFICE