00120153 (2) clBUONu ;krNo
BUILDINGDIVISION PERMIT CONTRACTOR INFORMATION:
IIUILDIN(iAUUItI:SS: PENMI'r NO.
0WNER'S NAMI1 APPLICATION SUB ME
JS PHONE SANITARY NO, CONTROL NO.
O K'!. ARCHI"r]iCl/I:NGINIiIiR: BUILDING PERMIT INFO
tw--,pOp BLIyG EIAiCI' PLUME, MECII
HW
5 y Job Description
LICENSED GDNTRACfnR'S DIiC1,ARAl'IDN
oO z-G I hereby alRnn thin I.,,I licensed under provisions of Chapmr 9(comnxncing
y„m'w with Se,fi 701N)nl Divisu 3oI he llneiiese and 11.'arc„iom Codi,.amdmy liccnxe
6 � is In toll li,mc Bal
K at h Lieens}•CI1u,$role �` I,ic.p Z S
°>2 o a° cunvnamrr} .Z _
'3 ARCI IITECa S DECLARA DO
C a I undersmad rip,plane shall he nsad:v public recoNs v
wi o ip LicemeA I'rofnsiunal
X OWNER-BUILDER DECLARATION
ul= I hereby ulMn'thut 1 u exempt fl'mn the Conminnl'v I,a'nsc Law for the
F]t folkwing mason.(Section 703 am
and Professions Cove:Any city or county
C which requires a permit m construct.eller,improve,demolish,or repair any stmaute '
i
3" Prort t I: 4 filll lb It fl y L'Ile,eel
that he is liansuall PursuantI the provisions r the Cultural L W 0cn pmr9 Sy. Ft. Floor Area Valuation
(Cournarlacilag with Sect on 9001)of Il vvion 3 of the Bus Rees and I ref sx ons Cual l
,r that he is exempt therefrom and the hrois lin the alleged exemption.Any vlolmiun -
of Section 7031.5 by any applicant for a Writ subjects theapplicant to a civil penally
of nm nnuc man five hundred dollmv($500). APN Number Occupancy Type
❑I,as ownernr tine property,or in,empinyms wish wages mtheirsole vont,ar anion,
w 111 do da• od,.and tis same n,Ix not intended or offered Ibr sale l4ec.9044.
Briant,..and Prole,ion.Cade:builds car Crummnnr',I.ianse law doe.,out aplty i,an Required Inspections
r of prtl Who r imIllpves thereon,and who Ilsuch work hlnmlf
i
or to nigh his awn employee, provided that such llnnmvermnu am not Intruded nr
offered 0,r safe.11:hnwevc,the hwlding nr ilnpmvemem v sold whnin one Yom'of
Lmnpinion.the owner-builder will have the burden of proving that lie did not builder
nlnovt.for putpow'Itvulol.
❑I,as rof the propany.am exclusively comructing ail licensed contractor,to s FINALED
istfuell Ih.projnet IS,,7044.Rosiness and Professions Cade,)'Ihe Cn I.........
Limnse Ww does nm apply m an owner il'prol>rry who builds or in,pnum
ves there -
and who contracts for such project%with a commch,d,)bcoamd pursuant m the MAY 2 1 2001
C'nnauulor"I.imnec La,
❑1 not exempt under Sm. ,li&1'c fur lis reason
°w"`r BUILDING
WORKER'S C'0MI'Date 'IUN DECLARAfIUN
I hcmby ulfirn,under penally of perjnry rune it the Inswing dodarniuns:
❑ 1 hme and will maintain a Ccnificam nth Conant n,elf-insure for Worker's
Compensation, us provided Bn by Sectiol. 3)1111 of abut U1,... Code, for the
pc,f mance of the work tiff which this permit is issued.
El I have and will iwimuin Worker's Cmnpanalinn Insurance,a,required by See, I -
39110 of the I.Ihn Code,for the pmlormance of the work far which lis pemnit is
wed.My Worker's Compensation In,umnce carrier and Policy number are:
Carrier. Policy No.:
CIiRTIPICATION OF INPMl'I'ION FROM WOKKERS' -
COMITNSA'IION INSURANCE
('11k metit r need not be completed it the penult is for one huidred dollars
1510111 or el")
I rectify that in the perto rof:ume of the work for which this Wood is issued.1
,hall not employ any I+',,,,a in any 1n,a IZ in s c .bjeglayrdh,W..kuM
Compnsmd quL ern Dpy' as - fr//VV
nrrfierum ` .Y!-/ ice eo
NOI'ICf:'I Al'I'LICAN"1'.I I;elmrnwking miscenilicm•nl' enlpnun.You should
veconw subject to the Worker's Compenwtion rrovivions of the Who Cale,you ems,
Q O !rhwim un„ply w ill well pralsion,or this permit snag he deemel revised.
Z .
h CONST,$Iia ONLENUWGAGENCY
F0a•1 5 hcrchy Whin:this permisu cunsd(See. Icndingagency to,the perfunn:rime
Lisa anrs for which this permit is issued lgvc.31109.Civ.C.)
5 Q Lender's Name
� 2• Lender's Addrexn -
V 0 1 vanity that 1 have mad this upplicatima and state that the above information is
1St lr c rrcm.I ager o Comply wl@ all city and cot my oolir:mcc,and ,am 6 t,relating
V to building coramciion,and hereby uulmire mpresenlativesofmis city to amerepon
rgg the above mentioned pmpeny for inxpenian purposes,
G (We)ugu to cove,iadennnify and keep huonless the City of Cupertino against '
Cn Iiahilities.judgnces,costs and as,mses which may in any way accrue again.said
U
City ia,consequence oSTANDSA DWEI this mat. Issued by:
APPLICANT UNDERST4NDl AND WILE.COMPLY WITH ALL NOWI'OINT
SOURCE.REGULAllONS.
Siliconrtafnppfin,m/Cnl,hatlor Did. Re-roofs
I IALARD0US MATERIALS DISCLOSURE:
Nil]lire applicant in l'mure Wilding'acupam mom ar handle harurdav material Type of Roof
a,defined by IIm Cupenlnu Mnnidpal Coca Cbup1cr 9.12,and the Hcohh and Sadly
Calc Smlion 25532hd? -
0ye, 0N All roofs shall be inspected prior to any roofing material being installed.
Will the apdw mor more bui]dm,occuplmt use eqaipriI or devices which If a roof is installed without first obtaining an inspection. 1 agree to remove
emit h,vardnw err eonmminuna as defined by the Boy Arca Air Quality Management
[);,Erica all new materials for inspection. Applicant understands and will comply with
°Yes ON. all non-point source regulations.
1 have read life bavmdnus materials equirctiems cider Chaim r 6.95 m the
Cut Heart.health&Safety Cook.Sections 2.5505,25533 and 25534.]undCotend that \
if the ildingdae,nnt cares 1,haveurenan6,h,it is au,m,,m,ihiIily m minty nm / L 4- —(9U
OcuPatn of tiler rens,when oma he ,let P11nr m uana ora Cm,ilicmC of
ccupancy.
�2 _ Z� ,. 00 Sita e o Ap :cant Date ,
ow , ,an ml Date All roof coverings to be Class "B” or better
OFFICE