00120143 (2)CITY OF CUPERTINO
BUILDING DIVISION
CONTRACTOR INFORMATION:
PERMIT
BUILDING ADDRESS
PERMIT NO.
1.9665 I«EEFdUTT m
LYiI tERT'INO 1=1_UI"IBING 001'
01.4:3
OWNER'S NAME:
APPLICATION SUR DATI:
rlr� u lrr ZA Dr.:PPA AND lhEl rna:
10237 s DE f4qZA H-V 12/
' /20wi-il
PHONE:
SANITARY NO. CON'IROLNO.
(408) 28,3 061.8
ARCHI'I'P.CI'IIiNCINITER',
BUILDING PERMIT )
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BLDG ELLCI sl. MI!CII
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LICENSED CONTRACTOR'S DECLARATION
Job Description
'
I hcmhy a(fml that I .nt licensed under provision, of Chapter 9 (commencing
nl-ca
with San inn 9100)of[)is-on 3 of the lhoinosx and l'mlexeiun,s Cod,. and my luno,
r a a
infull!oast an
i`t L,. «_%Z�
i SERVICE
F �T if'F_'/WATEF2
y
um, LZ _lisp c„mramore,""
act"' IDN
ARCI{ITECr'S
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1 underslad mY plans "hall need no public record.s
License) Pnoo,,iuwl
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f 1WNCR-BUILDHR DECLARATION
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I hereby affirm Lha I an, exempt Ilam the Conhersov's I.icen,a Law far the
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f,ldnsving meso.,(Scalae703L5. Business and Dore,si... CWCAnycirynrmunty
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slid y :.in l aro,m at, I. oxvc,doau of. p-a.Y I wrc
uCS ,p
prion I - 1. 4 fh pp1c.., hu,tah,pcorill II y J.tlnan
Sq. Ft. Floor Area
Valuation
thatI Jp t IM1 p . fth C r r:L L (Chptar9
(conua eing wllt Sccti n7gal)ol l*sj.. I d, le Bmness and Promsxbnx Cod,,)
exempt or and the basis far the allegcJ cxcmpfion. Any violation
or Lha he is
V
or Section ?031.5 by any applicant for al ort inubjects the applicant on civil penalty
APN Number
Occupancy Type
of more ore than live hundred dodais S500).
3163E004.00
01. a, owncndthe progeny, "r my ounno, cc, with sages., their "ode ,, mproodion.
Required Inspections
will do ,he work, and Lha "aucmre is out iro nd,d or olonal tin sale (Sec. 9044.
Itu,ines, and Profession Cale: The Contractor's Licanxe Law does net apply Ie an
rov nc r of prnpeny Who builds or improves Ihemon, and who docs such work himmlf
?Id'e9. '— l.1tsIDF_.F\'FL.00fi F9.1 t..
or ewe cntpleya,t provided ma, such inipnwnssol are not in,andod or
year
sale. If, hnwuilde the building or i i, that one year of
offered sal tentproving
�!�1 r�C�
1. — � I-4-l.11 0.r1NG '
burdenor he did
impletion, the ow'ncrhuilAa will have the harden or Proving Ih.l he did not M1niIJ nr
ikuaple ou
.RJ
upmvenrpu'poo,of,me.l.
502 FINRL PlAWID11,113 0,ERGY
❑ I, m oxncr of the a,,Nny, ane a,od" ivaly sou ra,an, wills licensed amuiv ars to
507 -- F11,44l.- r4. PIDING
nstmn the pojo,t 1&rc. 7("4. Bmino" and Profewums CtNeB'rhe Canhowter"
law Jsrs not apply man owner h ,,
nyefor builds or improves
o,n ,
and
h a co isho
licensed pnmuam t to 'h.
and wlio c"nu,eR liar cult) Jeep —ah a the
fin
Contrewou's License Lw.
01 um uempl under Sec. . B & P C far tri, mavm
.
Oxncr The
WORKER'S COMPENSATION DECLARATION
-
1 hereby our .m under panahy of perjury one of the following declarations:
I base anal will ntaiac,in a Ca,lit5cate of Consent to vell.imute for Worker',
Compensation. as provided for by Section 37140 of the lab., Code. for the
.
,serftenunce of the work for which this permit is issued.
01 have it will na.imain Worker's Compensaion I...... ot. on, requited by Section
39011 of the Labor Code, for the wrfunhanow of the work for which this pemtit is
,
My Wnrkcr's Conpc I ur.mv as mrunit Pohe, ounM
'd Pa i,>. No,: t»a 7.03 s y
All:
��pp.�yy%d�,
LT:RTIFt1X1 FIN OII!KEMIII'ION FROM WORKERS'
COMPENSATION INSURANCE
This "cclion need not be compldeul it the Isaiah is far nuc hundred dollars
,
(5100) or h,"s.)
1 cenlfy that In the perfumtenve of the work for which ,a, paned is is�twd. 1
shall not empdny any Noun in any ne.nner "o as m bcenntn subject I" the Worke,i
Co span"mien. law, of Cal'dmotoo . Date
AppRaam
.
NOTICE TO APPLICANT': If, after making this Certificate of Exempti(n, you should
suhjcel , the Wo k,rx Cninhwn"vllon pnrvl"ionx ,I he LahnrCn ho. you mus,
O Owhonte
fordrwhh cumply with such provisions .,,his permit shall he deemed revoked.
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CONS' I' RUC I ION LI!NOINO AGENCY
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I hereby of eat that stere is a construction lending agency for the performance
it he work mr which this permit is i"su,d (Sec. 3097. Civ. Cf
lender', Nam,
ZO
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Lender's Address
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I acnify that I have read this application and nam Ihat the No, Inliunnatiun is
La. [..
torten. h agree in cnmpl)' with all city and county ordinances and ,late law, a lafng
build Wg con"nmmion. and barehvnahariacre,sre adativas otthry city la cmcr upon
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the atone-nava ioned pa),., far sorsa i ......o.
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(we) agree to save, indcanify unit keep harmless the Citynf Cupot against
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fiubidiac,, judgment,, vou, and oyr,n"„ which nnay it, any way accrue agaimn said
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City in corecyuence of the granting of this pcnnil
�� _�T
APPLICA:y'U DRRSTANDSAND WILL COMPLYWITH ALL NON-POINT
/•7
Issued by Date
SNpRCEW 11 A' N.
Sngtumre of Apphcx lac DateRe-roofs
IIA9.ARDOUS MATERIALS DISCLOSURE
Wdi s,applicant... Imam huildingsteupan„I"re or handle hwardou"natcnal
Type of Roof .
d,fined by the Cupcnm" non o,ed Case. Chapter 9.12, and It. Health and Sefefy
cook. Sminn 2553200? '
0Yc" 0N
All roofs shall be inspected prior to any roofing material being installed.
Will heanpha.mm alm,wndingoaupam not c9nipnealno d,vicos ahwh
If a roof is installed without first obtaining an inspection, 1 agree to remove
emir hareems or contaminants as defined by the Bay Area Air UuAily Marugemnm
Uisiffa!
all new materials for inspection. Applicant understands and will comply with
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all non-point source regulations.
1 novo limn nuc Inoand! n ircrid« reyuiramem, ands Chnpe, 6.9.5 of the
' California Health & Safely Code. Section, 25505, 25531 and 25534. I mWccsu nd ,hal
if the building does not currently have a tenant, that it is any responsibility to notify the
'
Ih cquinn,cnn" wbich nets, he n1al prior to isvnuncc of a Ccnihc:nc ill
!z z-? -00Signature
of Applicant Date
"B"
All roof coverings to be Class or better
Owner or and tnr.ad asam Dam
OFFICE