01050199 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
13U IR S.:LD ING NIII2 NEWCASTLE OR PERMG'NG. 01,051171199
OWNER'S NAM1II:. bhHHI—L) —
APPLICATION SQ05ATIBO/2001
PHONH: SANITARY NO. CONTROL NO.
OKZ ARCH[TI1C+r,7ENCINEER: BUILDING PERMIT INFO
p O_O . BLDG [ PMIi MECH
E,c`� L I—I
6
LlclarvseuCON rgncTDR's 1)1;cl.nan'nGN Job Description
o ,uamoadimhlha Lmn Heca,ca tmaer pms;dons mfchapar9 ammmanei"g - 200 AMG UPGRADE
w with A<hlon2IXp)efDivision Sof me Owincns and l'ndcuinns Cndc,and my license
y sc i1 in full force and effect.
mite,6 License Clas^_ '_l - Liv.a �_
°xx'O n u Dam / �II Con"unor _
W 3 u.Ii, �• 11RCH1'"'S IlEC1.ARAT
L:"J O 5 1...."land ,,y plans seal he awed as puhlic record,
yd O�O Lkemed Pri fewnioal
a.o OWNER-BUILDER DECLARATION
1 hemby mi mut 1.,is exempt fortune contractor,License Law for the
F Z m. following mason.(Section 70315.Business and Professions Cnle:Any city Instantly
F C wh h restores permit tonistract. ldprove,demolish, repair any stmcma,
3m pno,fl al 1 ' :tl ppli If hM iu 11 6cJ stem nen
that tic l :dp - ItoJhQ1 I luec f.mors,1 Lu,(Chaplet9 Sq. Ft. Floor Area Valuation $0-
I....too,a g wilts Se'lm'IIXXI)of Dlvu,h 30 div Basin and Probe..tons Calc)
or that he is exempt therefrom and the basis Iia the alleged exemption.Any violation
of Section 7031.5 by any applicant for a permit subjects the applicant,a civil penalty APN3`Fu6itDer01�. 00 1 Y YP
,if amt mote that five hundred dols.(S500). Occupancy Type
Cl 1,us owacr of the pa,st,d.m my employees wilt wage,o their ,,In compcosaron.
sum dm me won(,and the Ykno v I,as intim all a littered 1b,Xme(See.2044. — ROR�iHtdir�►�$C[2tPQRL
ba,incss and 11 1 ..imms Code,'fhe Comlmemrs licence Les m
aw doact apply an - s,04. ry
urr of properly Who builds or in,pmvev themon.and who does such work himself 501 — FINAL ELECTRICAL ENERGY
through his own employees.provided that such improvements are not intended or
offered fa ale.If.however.enc Wilding or improvement is sold within one year or 505 — FINAL ELECTRICAL
completion.te howner-builder will have the burden of paving that he did nut build ur
mprove'a'""T""of sulc.l.
E3 1, f'he p 1 1Y ownlo,ier
IY ( ( Fwin I (uta :n.
consumer 11 project(Sec.2'44 Bane dI f ., nsc 1 �)lin Contractors
1 Je.not apply 14 err f a perry hoIJ P th re n.
and 1 t ens 4 h projects withcarnations) sed pursuant to the
❑I sore r,nhml anger see .o cur PC formal masonI
Owner Dme °I
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one of the following declarations:
❑ 1 num and will maimain a CCndicmQ 'If Cuoscnl or Idf-insure for Worker's
nmpcoo; dna, as provided fur by Section 32(X) of the Labor Celle, for the
pert oosome of the wink ka which this permit is Issncd.
❑1 have and will maintain Worker's Compensation nomarm.to reyulred by Senion
370s9 of the tabor Code.for the perfirmarm,of the work for which this come is
issued.My Wmkers Compensation Insurance currier and Policy number are:
Carrico Pulley No.:
CI7RI'1 FICNI ION OI'EXCMI11'ION FROM WORKERS'
CUNIPENSAI'ION INSURANCE
m is action need not W completed if the permit is for one hundred dollars
I$I00)rr los.) '
1 certify than la the pedone on of the work for which this wornal is i,s md.I
.bull nu(ampiny u y Iwrmm�in:::hr::,u:n,a son, p �n 't to mm Workers,
Cn:npensuflon Ice nil'min D' Q
npplr-m
because
subject
Work: .aft inking thisainincmte of,UWr Cade,n. you
becomeh comply
the ouch Worker's Compenmthis Previsionsll the IoM,Cale,you soot
'Q O fnnhx:tn rnnhply with such prm'iaium or this Permit shall be Jttn¢A revoked.
Fti CION SI'RUCTION LE N UI NO AGENCY -
C ' I hcmby affirm that farm Is o nmstmm(ion leading agency for(1 11ln11 1ice
of the work far xhiclh this pemnl is issued(Sm.Ant.Civ.C.)
L Q I,cndcr'n Nater
._ Z Lca, Add.,,
V C1 eerily that I have aaA tai,application unJ sate 1hm the above infonnu(ion is
W F�.f ,ren,I agree ,,comply with all city and anunty nrdlnuncaX and wrote Inws refining
mbudldingenn(mndun.aaHhcmby mehurmrq,re,vnmflvcn ter mlscnytoemaulmm
bene ahnvonamiamQd property as iawpemdon papal",
Fes` y (We).gree msave.indemnify and keep monde,,He City of Cupertinm-gait"
Vi liabilities,judgments,costs and expenses which,nay in any way neem,against said
V z Oryin con one neeor the 8mming of tris pena
APPLICA RSTANDSA' WILL( (PLY WITH ALL NON-PONT ISSHCd by: DIIIC
BOUNCE l_`AH NS.
Signamrc nl'Applicnn 'on1r �— Re-roofs
ITA%AR1555YYYfffUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant store or handle harardous material Type of Roof
as defined by the Cornier)Municipal Cale.Chapter 9.12,and the Ifcalm and Safety
Chante,Seen,,.25532(a).'
Cl Yea Nm All roofs shall be inspected prior to any roofing material being installed.
Will omr, i,i(m,mom lauding w,apanf u,e eyuipmemor device wh0l If if roof is installed without first obtaining an inspection, 1 agree to remove
emir hatun om air commmiranl,as defined by the[lay Area Air Quality Management
all new materials for inspection. Applicant understands and will comply with
.
El yes `Nr, all non-point source regulations.
I have mod the haiantous materials re9uirctred under Chapter 6.95 of the
Califiar l,Ilcahhte Sal cfy( ,III,Seed o..2$505,25533 and 25534.1 und,r,ur (dial
if me building docs nn1 cuncnlly have a wnunl.lha II iw my respon"hili(y m nonl'y 1bc
ccupnnhh mf me, rvir nn wldrn aha" ff f pea( ysu,:aa ter-crrdrrmc of
ace° °y' Signature of Applicant Date
owner. uthmri.ee:hgen, — uat� — All roof coverings to be Class"B" or better
OFFICE