00070104 (2) . CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
RUILUING ADDRESS: PERMIT NO.
QIVNERS bllb974 NORTHSEAL SO SUPREME AIR SYSTEMS APPLICADO6&f6104
ONE: S U'RY N . ON .
DAUBER STEVEN M 520 MCGLINCEY LANE #1 7/18 2966,
X 0 0 ARCHITEC'n ENGINEER: BUILDING PERMIT INFO -
- (408) 879-0334. ti1.DG ELEM PLUME MECH
F t d, I LI I-1 =1 I-1
^F N j LICENSEE)CONTRACroas DELARAnoN Job Description
Z_ 1 herehy adult than 1 am licensed under pool Call ar Chapter 9(commencing
t=== with Seatlooc an,cfD at cBusinc.x and Profen Call.and mYlt
<m is in full tone an,e1I a ./t /TIJ
g zo c Licen,e Chir._- Lie a—t�yT(tS (IX-/C( Y
s U oma -_ commcmr,
rt � . rs o1:c1.nR AC UNIT
1 un Lod nay aux shall M+Usad a>rnmic rccnNx
��
Prof..iaml
a o y OWNER—BUILDER DECLARATION
1 hereby affirm Thal I am exempt from the Convenor's laccnw haw for the
!—z a following ruawn.(Section 7031.5,tiu,inas and Pmt.ions Code:Any city-,oun y /O
f i C which rcyuirc%a permit to cnn>tmct,alms inapmvc.Jctnnli.xh,nrreran any structure
i3m prion,,its issmmrq ala.re,im,he applicant Rutstein pennino file asigmd.antement
mat he is licensed paronatint to the provisions of the Cratmi Ijecro,Us,(Chapter 9 Sy. Ff. Floor Area Valuation
(commencing with Section 900()ofD'miril 3 ol'the Business and Profmxions Cale)
or that he is exempt Ihctcfmtn and the hasix liar the alleged exemption.Any vloltnion
of Sectio,7031.5 by any applicant or it vrout wblects the applicant it,a civil pcnmly
of not Iname than five to diad dollars 0$50n. APN Number Occupancy Type
❑1. awrvrinaeproperty.ornty anployaerxina saga,as their'efeeotnpenxatlon, Qt
will do the work,I I lm situation in all intended tit otfcrcd lin.ads(Sec.7044,
!In meat and It lic..ion.Coda:Thola
Till cmel tss Lietnxe haw doe'alt apply ,,aIn & yuired Inspections
In Ibteat pru,aat y Who huillL ar intpmvc Iha+xrtn.;all who doc....elt sank hitnselr 31.640033. ILI
nntgb Ins own ctnployas,p)skied tent well Impnwancnlp ata nor iutcndal lir
attired b,rale.IL ho,a'aa Iha building or Ilnpnrvenmtn it sold within one ya.i,0
nI'ledon,meowner.bwmer will have the nanbn of poavang that bend not build or 703 — ROUGH MECHANICAL
etude fnpttrpos ofeme.). .,
❑h ar owner of he pmpett,nm cxdtnivmy orraclin,with limmrl....oan.... o 304 — ROUGH ELECTRICAL_
el the project(slt eeu,a.7044.If...nt.'and Pridr,,itI,eosin:)The Cono-aatn" - 505 — FINAL ELECT R I CRL
License Law Flax aI,ly n ownerr pm
operIb
y who b tild,or ilnpmvn, ern 1.
and who common❑,r'nch planers with:t artrac'no)li'd-0 pnrsaaal m doe 508 — FINAL MECHANICAL
Commemo's License Law.
❑I un,exempt lmder See ,R,C It C lin lh,,reason
Owner Du¢
WORKER'S CO4IPENSAI'[ON DECLARATION
I hereby affirm under penally of perjury one of the Billowing declarations: '
1 have and will maintain a Certificate of Consent m sdGinwre for Worker''
Compensation, as provided for b)' Section 3700 of the I.ahor Codc, for the
ace of the walk for Onah this remail is Visual
I 1 have and xiR mainum Worker's Compemmtion Insamnce,as recoiled by Section
,fF hhe}ISLaM Code,
7�'for the terflorniance of the work for which this permit isis
ued
Csaller' '•'r ��'" a l'aycY Nn 1f�',t}�IJ ,IiIu:Yn�u/mJ�he
CERTIFI(.ATIONOFIiS( iVrIONI'ND�Ii RKERS'
COSIPENSAf ON INSURANCE
(This section mal not be c npletel if the penmil is for one hundred dollars
15100)m less.)
1 certify that in the performance ill tire work Int which this remail is issued,l
shall not employ any person in any manner ma as to bnemne'ubject to the Workers'
Com'ta'diou laws of Culiromia.Dam
Applicant
NOTICE TO APPLICANT:IL alter making this Cenilicuro of liIa mption,you should
become subject It,the W'oder's Ca.Owatoina...... loos III the Lahr Code,yna mixt
fovhwhh(cart,with inch tons it....or this permit xpJl be deemed rooked,
CON S'rRUC'I'ION a I.ENDI NO AGENCY 7 1 herehy affirm that there ix o mnswctim1 lending mlcncy tar the perbanname
,,f the sod,bat which thin pennit is Issued see.3097.Civ.C.)
Q Lemftr•s Name
:. z Lendcr'e Allies,
U 0 1 cunily that I roi,rad this appllvatln I and vane fiction,uhavt infunnatlnn is
W n ncm 1 agree m..... fy wilt 411 any Doll manly urdmanucx and wtm lows mlming
V In huimmg L"It" inn,ald harahy nmhori r,macmmlves of thio city to untur upon
the nbove-mmftmned prnpany for inspection purparcs.
y (Wt)ngmc to east,Indemnify and k.,bartnle x the City of Cupertino against
V) I arbllaw,,judgntans,ea,Iv:mA expensel which may In any wry:talian;lain"said
U z Gly in eon.ellntnae 01 Ill g,I in,of this pertnit.
APPLICANT UNDERSTNDSAND WILI.COhP1,Y]hTIIAI. ON-POINT Issued by: •Date
501 =GU` TIO /S , (� —
.tgnawr 1 pNicand6 mmmmntL]p[�/�•�—amt Re-roofs .
HAZARDOUS MA'IIiRIAI.S DISCLOSURE
Wil the,i or future Ordains tnatpam more m handle Ma:wou,material Type of Roof
us Joined by the Cupertino Munici,d Code.Chapter 9.12 and the Health and Safety
Cattle.Section 25.532(1)!
❑Yes ' El No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant orfuture building melanin use equipment ordevices which If a roof is installed without first obtaining an inspection, I agree to remove
tomit h:arardoo.air commblnatio ns defined by the tiny Area Dar Quality management
'arfe, all new materials for inspection. Applicant understands and will comply with
oYex 0N all non-point source regulations.
1 have lead the mia dom materials rccuinntems under Chapter 4.95 of the
California Heullh h Sufay Code,Sections 255115.25533 and 25534.1 unJnwand I. -
ifthebuildingdoesnolcuneml)'have a tenant.that it it mymxpnmRuby only.
'p Pam of the mrluirctnenn which must be met prior a,iouance of n home f
���`-�,//( L /}' ignature of Applicant Date
O�erOramhniagent II —I— All roof coverings to be Class ..B,. or better
OFFICE