00070192 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADIjR.S�' PERIll E N(000 71(I:I.91C.?
I1r.: CI...r: ..d_IM RD ��M .�c����(��h� ,Z.✓c
OWNER'S NAME: APPLICA11��11�'Y 1% ..000KC&J INVI_S'ITIE"1IT Nfge sf� ,e�✓C
PHONE: SANITARY NO. COVI'ROI,NO.
C eL Z ARCIIITECIENGINIiER: BUILDING PERMIT IN[;()
O BLDG ELECT PLUMB MECH
y= LICENSED CON'rRACD)R'S DECLARATION Job Description
�d Ino Ihetehyafftnnthin Iant licemed under psviaim,of Chapter 9(emmo:encing
pv.tw wi,hsection]U01nfDivi.innJoftheBminl.wndl'm � t�:nndtttyreen,e DF.:IvIOL:C:LTOhI OF SJ:NCiLL Ff�IhIl_Y DWELLING HOI
=t is in full farce and ell
s 6 Liccnsc
CI Lic.p
O a O Dole y/ (7 S DECLor L)' f` JJ
w 3 a y ef/ ANCHITECI"e DI%public re or
1 le tend my plan.zhall M1e uaed:,public tnumk
r
w 0, Liccnud 1'ndcsional
d Pit� OWNIiR-BUILDER DECLARAI'I(1N
I hereby Italian,hut I am c"enip,[sunt Re C.... 's License Law 1'or the
ZZ 2 hollow log reason.(Salton 7031-5,Brom...and Pmfer,.innv'Code:Any city ur county
z o which requires It Mmot ui nmswc,."hci,improve,demolish,or repair any mature
a3�
prior o its issuance,also activities the applicant for such pe nim,to file a signed emromcnt
that he is licensed pa,u.nt to the pmvisinn%of the Cantmmnr.License lww(Chapter a Sy. Ft. Floor Area
(enmmenn ng with Section 7100)of Did NI 3 of the Ba.einess and Psfessions Code)
or but he i,escmp,therefrom and the W%k for the alleged estimation:Ami violation
of Semon 7033Is bynay appm
lien favi Pcmtit able,,,the tgm tplWant a 11111 p"Inty
nota mote Rtun foe lmideddoll...(ssaln APNy,,AV lao[ Occupancy Type
❑1,d owner of the and
the y,nnny mato t in with doges offered
f sole ie(S motion.
will do the work,and the vsnum i%not intended en oflLow for sale apply toBin.
a
Boniness andpro erafe.Who
Case:The Contractor's,and w o d does no,apply m an r,.. yu r 3I 1 t'
r nr nrapeny won nn'ud,m amprovpx Election,and who dttes such work bitIs 1,I1:) 0C.),.l.l.CINE
ar through his awn employee,.Provided that xuch impsvcmcar,arc not on, let (ir
olrercd for sale.IL ha"'c'the Wilding m i u'ro'cu ent is ,,to within one you of
iompletion,the owner builder will face do,hoiden afproving that he did not build or
mprove for put3"ofsale.).
Cl I,a,od ser of the prnpcny.in.eedusively com.c,ing with licensed common,m
Lammo the psiec,ISce.7044.Hun and Profcse s Codc:l 1 h Comcmbtr'I
iw c I,nw cwt out apply bt i nwnctem pmisrl,w111,1)iIds...:nips c,thercm.
and who am,mwn I'm sudt pmjec,with"contact licensed per want ,,the
Cmttmemt's I.iccmc L"w.
❑1 ant escmp,under Scc. ,H k PC fur,his reason
Owner Ilene
WORK HR'S COM PI!NS NJ ION DEC LA RA PION
I hereby of nn under penalty of Perjury one of the Iidlowing deelamtimI
YI have and will ma,min a Certificate of Comsat to self-Inmm for Worker's
t
mpsmminn, as prosidcd for by Section 37W of the Labor C.R. for the
performance nf,he work for which Ni,permit is IssneJ.
❑1 hose and will nerinmin Worka'.CompeniN ion Join I,as elicited by Section
3710 of the Labor Cala Ibr the per!it: ce of,he work for which this permit i,
swttl,My w'arkds Cope...too Insurance carrier end Policy numbertire:
Cartier. Policy Na:
CERTHJCA'I'ION OF FXI!MPI'ION FROM WORKERS'
C'OMPENSAIION INSURANCE
(This section need no,be completed it the permit is loiane hundred dollars
(SI(d)or lees.)
1 certify that in,he performance of the work for which this permit i,isoned,1
shut not r "y any Pawn's any nmts r.o a,m beco n,xahiect it),he Workers
Canpw
tmaioo
n Laos f Cnllbvmia Date
Ap,1wint
NOl'ICE:TO APPLICANr:If,after making this Certificate of E.con,ai gnu should
become,subject to the W'orker's Compcowtion Provisions of,he IyWr Cattle.you mus,
O forthwith comply with such pamtkium or this permit xhall be deemed revoked.
F ^ CONS,RUCI'I ON 1.17N DING AGENCY
Ihumby intron that the', onrmnding
I, eatimt leagency for the Pcrl'arutance
of,ho n.n!for which this grmh is listed(Sce.3(0).Civ.C.)
L Q LerI Name
Q Z Lender's Address
t> O 1 certify III,1 hm'c read,hi,uppliention and state that the nWve infornrninn is
Lit pq ccro,,I.I agree et comply with all city and county onllnun"a,and stat laws relining
V m.Within,construction,nod III wti c represcnmt loss of III 3 city m enter upon
W the tiWve-mentioned pntpeny for inspection purynse,
i IS. (WQ agree to,ave.indemnify and keep Wordless the City of Cupertino against
1 tq liabilities judgments,coos and espeme,which may in tiny way acc.c against said
U z City in comwNuene,at the granting nr thi,permit.
�t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date /
SOURCE REGULATIONS. y'
Signature of A,,licarm Conmicmr Date Re-roofs
HA'/.\RDOUS MATr:RIALS DISCLOSURE
Will the applicant or future Wilding oscupun,score or handle huddhous matcmd Type of Roof
ns deincd by the Cti,mro Mmlcipal Calc,Chapter 9.12,mW the Health and Safety
Cock„S" I25532(u)7
yc 0 N All roofs shall be inspected prior to any roofing material being installed.
WII I the applicant or future Wilding docupatn in equipment or device.which If a roof is installed without first obtaining an inspection, I agree to remove
emit luranlous air conterminous a,defined by the Bay Arca Air Quality Management
Domc,I all new materials for inspection, Applicant understands and will comply with
• r`'_" �Nn all non-point source regulations.
I hove read,he harallou,materials equrcntems tindcs Chapter 495 if he
C"lifomi”Heal,h&Safe,,Code.Sections 25505.25533 and 25531 1..&,tend that
if the Wilding docs not cumently have a tenant,that it is my rc,portoo ity to mady the
acce—_.-of,he rcqui cments.1,Sit mus,he nm,prior,o:.,mane of a Cet ificate of
Occu "nay' / to Signature of Applicant Date
oxnaaamh / 3 Daae All roof coverings to be Class "B"or better
OFFICE