00020103 (2) - ------- ------- -- --
CITY OFCUPERTINO As t Of " z PERMIT NO.
BUILDING DIVISION PERMIT CQ, 'oCl2A„,CT% I)\l -ORMAAA SON:. �ddO�t�
BUILDINGADDRBSS: Q •^`. / 1
2 'L$ S 11 R 1 1 Q M'e1j 9' IN SANITARYND. APPLICATIONSUBMITTALDATE
OWNER'S NAME: aV 111^^^��� I/ sC—Q,K �c lar NIC CONTROLp
A '11111-cm,
PHONE: /1 / 43 L
RaHTECDENGINLERt� l C BALDING PERMIT INTO
00 v
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Z F i LICENSED CONTRACTOR'S DECLARATION
o z— 1 hereby affirm that I am ftm Ist ind, MProf ssof Chapter 9 my lice.
Job Description
t,:(:•�
with Section IherTyaffir DthatI ml ice BuaiseseeMvisionsiof hade,aMmmienci is C„�//
in full for.and effect.
iO u Lns
lue Clan LIC.N NC N P�
3 a y Dose - Convector
ARCHITECTS DECI:ARATION (V/,
y•�] I hndennM my plena,Mil be arm n Publi<rtcwda
e Asa Licensed Professional _
OWNER-BUILDER DECLARATION
< 1 hereby Byron that 1 am exempt from the Commences License Lew for,the
Q following reason.(Section 7031.5,Business cod Prolrsiena Cade:Any city or county
which requlro a pmmil o con amen,alter,improve,demolish,m repair coy memsecc m pnwmiu issusnce,alaa requirtsthe spplicem for ea ch pmtduo fileaeigoedautement Sq. F[. Floot Area Valuation
Nw he u licensed purswnt to the provisions of the Convsetms License Isw(Chapter 9
(cpmmcncixl with Section]000)of Division 3 of the Bwinsas And Pmfeaaions Code)or
thin he is exempt therefrom W the basis for the,elecath exemption Any violation of 3 APN Number Occupancy Type
Simeon]031.5 by coy applicant for.perom mhj.is the m,licwt to a civil petWty of
Qt thw five hundred dollar(SSW).
nwre Les owner of tine progeny,art my empryen wish wagonthev wee campenation, Required Inspections
will do Ne work.eM lheavamum ism imw0.tlmoffe m ]OTA,Ban."
Profession.ofeauans Codmor
e:The Conm 'a o w owmcr a/
AMProProf who built or i n w coo 1f or mroulh
We
in
I i a offered for
f,h d rte yevof completion,the
-lanai no et he d'Wn improve fm put- ,
r of the grope a iv c sad convanan to ��
consa Ne p c. m Convectorf And
t/O O
U'rya�g�� to runpovo thmeop.cod Q
co:6Cn inch j uw giicensed u t VNlare
Pan Sec. for
R S941M DECLARATION
re n yofperjuryoneofthefollowingdeclsrtiwa:
7 meinnoir a Cirm 37 m of m.LAIna rode,fote e,perf kees ce.f 1h-
tion.es hichm i for b11 Section 7]00 of the Libor Code,for the,perfemunu of the
wwkfor which Nia 1411t is oft,
❑INeveWwill
oca,fon Wn Performance
Compensation ofthe w Inwor which this
Per by Section
myW theLibor Coca,for the pnforuweofthewwk farwhichm: permit is jawed.
My Workers Compensation Inmrastce earner And Policy numbo ere:
Carrier Policy
CERTIFICATEOF EXEMPTION MOM WORKERS'
COOMPENSATION INSURANCE
(This acctinn nem icon M completed if Nepmmit is forooehuptheddmlan($100)
wince
1 unify Ow in the perfomurceof Ne work forwhich Niapemdt iainum,I shall
not employ my Peron to Any manner w es 1p hcwne wbjectmpen-
sationl,BwrcfCalif ia. �� o "wL 1 3 c
Applicant
NOTICE TO APPLICANT:IL after makingCertificate of Exemption,you should
mr
becoe aubjecNWaekera
l to e Compcnssuo mvisions of the Ulan,Code,you man
forthwith comply with each provitomw or this permit ahall be dsnrcd tovokM.
CONSTRUCTION LENDING AGENCY
0 0 I hereby affirm Nu mer is A connmction lcMingagency forth,perfmrweeof
Ne work for which this permit Is issued(Sec.3097.Civ.G
ar Indere Name
y LAM esAddmxe
W Q 1 cenify,Net 1 be.need mix application mot that the shove m omanu n is
contact 1 agwe to comely with ell city nM county ordinance.AM aux laws relining A,
z building concoction,And hereby authorimrepreaentiives of this city te,enter upon the
V 0above-mcmianed property for inspection purposes.
W Ey lWe)Alone m save,indemnify AM keep harmless the City of Cupcmm,against
0 V Iubilitin,judgmenn,costs and expenses which may in coy By Acme agarol mid City
�+ oil in comsequetre of dr gmndng of Nia permit.
► y APPLICANT UNDERSTANDS ANDWI LCOM 7C0 /,WI rH ALL NON-POINT
V Z SOURCE REQ UTATIONS.
1 t Sw c �/� a��
S19motion of AMIIcwd ontrmtm Date
F5A7AARDOUS MAT R ISOISCLOSURE
Will the applicant or future Wildi cupwt none arthWie harshen tturend Re-roofs
As defined by the Cupenino Municipal CMe.Chapter 9.14 cod the Health And Safety
Cmc,section 25572(a)] Type of Roof
El yet
Will the Applicant or fmare building erwpwl aa, which All roofs shall be inspected prior to any roofing, material being,
emit hound...eircontaminence at de6rcd by the Bay Aro Air Quality Mwagemcm installed. If a roof i installed without first obtaining an inspection
7b"Bilding
`"°"" �,� I a res to ,move 1 new materials for inspection. Applicant
Yes
I have read the haasrdoua memnala rtquimmenn umber Chapter 6,95 of the Cali- un erst s an ill comply with all non point source regulations.
rme Health&Safety Code,Sections 25505,25537 And 25534.1.oder int that if the \
does not commit haven eryynI Nat it' ny ruponibilkywar ifylhemcupwtf Nemvwhi tmoat b RutcSignet re of Ap i retDate
wro'co mthonem Olen Dau
All roof coverings to be Class"B"or better
OFFICE