00060167 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUII.DINGADD e..�160. LUCKY UnK CT PIRMU-NO. 00060167
OWNdilR'SNAMVRVID TOWNSEY APPLICATION 11218)`2,6/2000
PHONE: - - - SANITARY NO. CONTROL NO.
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Oram ARCIII'UCT/liNG1NEER: BUILDING PERMI FINFO
WOO BLDG ELECT PLUMB MIiC11
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LICENSED CON'FRACrOR'S DECLARATION _ Job Description
O y hereby a1Rrm Ina 1 am licenced under pnrvisionn of Chapter 9ldrmmencing .
PEi wohS,mmm7ato)otla,ion:„nheBu,i.c,amdProd,ieI,Code.tomalyficerle AC/FURNACE
is in full force and dhd.
a z 6 6 License Clary L c.hr
O O Data Contractor -
uN1 5 LL ARCHHECr'S DECLARXHON
°4 1 understand my plans.hall be used as public accords
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KK rA Q Z hi<mncJ Prncenionn
y o y OWNIi -BUILDER DECLARAI'IHON
W_w 1 hereby affirm that 1 am exempt(man the Contractor List Law for the
H Z T dolhosing recon.(Section 4031.5,Ila,ince.,and Prote,ionr CWC Any city or county
pwniuh mcid'ev a pear.:.to mo.anet,alter,improve demofun. a repair airy structure
it
Know its issuance.al.sorequiresthe applicant ter.such permit tofileaxagned statement
a
for he its licenced pursuant to the provisionsefthe Contractors License Law lChamer9 on Sq' Ft. Floor Area Valtf�ttiq 0
(fen.mcncing old,Secti70W)ofDiv' m3 of tire Butincrs anti Profineinn.Coact J
or that he is esdnla thareGom and the kris for.le alleged exemption.Any vinlaion
of Section 7031.3 by any applicant for a permit subjects the applicant to a civil penalty
of not marc than fm hundreddolln..(55(X1). APN,13(lu47007 00 Occupancy Type
❑I,a,owner of the property or my employees with wage%as their sole dmnKr satlon,
will do the work,and the standard i,not intended or oRemd for sale(Sec.70,14. !fa �per❑❑ tt;;�����1.�qa����p¢¢{{I�(��s
Business:cal Pr re,"ons eWe:'I he Contractors Been,Law dome not apply to an 303 — RoL Rriii%k LRmf41l.HL
w r om
f ppeny Who builds or hnpr acs Ihenon,and who doe,sucn work hietwif
or through his own employee,.provided that such improvements arc not intended or 304 — ROUGH ELECTRICAL
offered for sale IL however,the building or improvement is sold within one year of
coarladion.maowner-budder,will nava ma burden of moving mat le l did buildm - 505 — FINAL ELECTRICAL
improve forpaBmee inside), 508 — FINAL MECHANICAL
❑1,is nwaer o1'the pa,perty,tan cxird,ery commilio,will Ildmecd coal a,r to
construct the project(See.7144.Business and Promision.s Coded The Contmctnr'e
License Law dues not apply m an or,of pmpsay an,builds or improves thereon,
Ewho attracts tin such princes with a sontmctroo licenced pursnam to the
nn rremr'e I iccoc Luw.
1 am exempt under Sec. .li&P C for this=so `
Owner E
WORKER'S COMPENSATION DECLARATION
1 hereby affnn nn&r penalty of perjury one of the follow my dadamtions: 0
. ❑ 1 have and will maintain a Cer ificute of Consent to,e117-in ard,for Worker's Q
Compcmation, as provided for by traction 37113 of the Lut Cada, for the
per onnance of are w,,,k for which this permit n.!,,add,
❑1 hive and will maintain W'orker's Compen.aion Insumuce.as required by Section
3700 of the Luhnr Cwle,far ate pedimnunce all the work for which this permit is
Issued.My Worker's Compensinam In,varanca caner and policy another re
Cacti¢ Policy Na:
C,CRPII9CA'1'ION OF 13XEMPoON PROM WORKERS'
COMPENSADON INSURANCE
(Thr,sad on need no,he con..lend if the permit is for one hundred dollars
0100)or lase.) -
1 cenify that in the performance of the work for which this permit its issued 1
- ,hull not employ any p...un h any I cr so a,n,bm id st b,ioc,to Its Workers
Connpemohmr Law,of Calilamia.Dam
Applicant
NOTICE To APPLICANT:If,aver narking.hist Cenilicam of hord,tiuI,you should
becumesubject o the Wl,Omr,awad Flavin"at the Luhnr Code,you lana
Q 0 forthwith ctoaply with such provisions or this permit shallM deemed revived.
CONS'I'RUCI'ION LENDING AGENCY
a ' 1north,aid..a that them is a construction lending agency lin theµrlormanee
of the work for which this permit its issued(Sec.AN7.Cir.C)
Q Lcndcr'.None
1.cadcr'x AJJrn<e
V 0 1 reality that I have read this application and.vane that the above information i.
fat [r cormv.I I'me m cnnq,I"with all city and county I'd owe'anal stile law,scming
Q V to budding cnmtmnion,add Imoby truthorim repremmatives all Wil city at enter umm
} fad the abuvementioned pmpeny for iii,maiam parry,.1.
Fns a. (We)name a,snve,Indemni fyaul keep hum the City of Cupertino ugnimr
(4 liabilities,judgments,cots and expanwe which.nay Ila tiny way deme aguin.a avid
4.7 z Airy in U D R the granting of this pemnt. �_
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINr Issued b Date 2
SOURCE REGULATIONS. y'.
Signature arnpphaaucamtu
naar Date Re-roofs
I IALARDOUS MATERIALS DISCLOSURE -
Willlheapplicuntorfaturebuildingoccupant sane nr heart,board ondaenal Type Of Roof
as de5mad by the Cupenine.Mialkipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532fa1'7
El ye, 0N All roofs shall be inspected prior to any roofing material being installed.
Will the appfi.atormwrehe,ildingoccupant use equipment ordevices which If a roof is installed without first obtaining an inspection, I agree to remove
onithm.minu.air mnmmin.rnhrodehncd by sire BuY Area Air Quality Manuganvm
Dlittnc,7 all new materials for inspection. Applicant understands and will comply with
❑Yes L3 No all non-point source regulations.
I ltme rad the haaadoas mm.cdats roximenand under Chat 6.95 of tine
C.1hu mia Health&Safety Code.St...I,n505,25533 and 25534.1 understand dual
if the building does nut currently hove a tenant,that it in my re.mmsibilay to notify the
cupate of Ile rcquime dos wblch meet he amt prior to issuance of a Cmlfmare of
ocOti acy' Signature of Applicant Date
Owner or d,...rood agent [)..at roof coverings to be Class "B"or better
OFFICE