00100111 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS' PERMIT NO
OWNER'S NAME: APPLICATION SU13 DATE
ACE AND M 1
-41
ONE: — — SANITARYNO. O Lp O.
COO ARCIi1TECr/ENGINEIIR:COLLING - 1 .PE A 1 1
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BLDG ELECT PLUME MECH
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fpNj Lrm thalEDCO\TRACTOR'S DECLARATION Job Description
1 horny union That 1 Conn oftheaB under pod limns of bhCode)nit mnncing
F 4 C°w w�at sermon Jlga)of Dlvish,n 3 afore Business and Pmres.ion.ewe,Conn my.licenrxe
¢m S i.in full more and effect.
z
R.-< Lievnte Clas. Lie.a
0 n U Dam Contribute
ARCHITIi 71'S DECLARATION
C —i1 nnJvaomd my plum iter be ased as public plonk
has FIREPLACE CHINMEY REPAIR TO THE PLATE
wap e
C Lic,ns,J Priv .sional
UN'NER-EUILD-R DECLARATION
i:i LL 1 lrervhy uffimp th:a 1 and eor,,from the Contractor', law for the
C Z 6fallowing brao n.(Seen 19031.5,Is
m.i nd Mole„io Tip Code.Any lily OF unry
p which bwuimn a permit to conarvCl,alien,lmprove.demolish.or repair July murc
sru
n3- Frionons ixonowl.ilso lerrviewthe vpPlicam 4n,uch permit file asisnedaalemenl
that he is licensed pursuant tothe provisions nfthe Contractors ueen.el.aw(cnaper9 Sq. Ft. Floor Area Valuation
conconn,
mg with Section 70(n))of Dig n 3 onhe aurins and Profo uo-Code)
that he ewnrpl far,cl r it and the bwi,I...r the allied sal OfionAny vmlali
.n
of sccaon 7031.5 by any appnc,m for o perms subjects theaPplmam to a till penally
of no ream, hmfivehtmde,ndollars(S500). APN Number Occupancy Type
❑1,m mw......f me prnlven,or toy umploy,e,I wages o,their I'll comlp,n,mion,
v,01 do the work,and the structure is on intended or,Meed for sale(Sec.9140,
Ilmones,and Pmfc.,ior.Cone Tire Commetr,L.Iven,Law dive,nat apply ,,an Required Inspections
owner of property Who build,or imi thereon,and who ores such work himself
on through his own enployeas,provided that such Improv cuts a not intended n
Rered t cede.1L 11-111i.the hnddie t or iommveta,oi�s sold within one year ai 369250105. 00
,nrpation.me owner.huildi will have are humle t of proving that no did not bu'dd or
improve lr no we if vale.).
❑1,asof the property,a eXtil-lny contracting with licensed eontnmol.m 101 — FOUNDATION
or,nmen hire projectaec.7044,Online,,am]Prol,,ion,C ]c,)1 he C...amctor, 31 — CHIMNEY RENAR R STRAP'S
1 icenm Law does not apply in an owner of property who batiJ,or improves thereon,
and who contacts for such project,with a nm inalmov)licensed parent m de 514 — FINAL PURLIC WO R
c'mro r.I.icen,e Law.
0 ,in cmn,,1 under See. .13 A VC fin Ihi,rrtdsu /
Owner DateO
WORKER'S COMPENSAI ION DECLARATION
I Iwraby affirmunderpenaltyof Ninny one of the fullowingdeelamtinas:
ij I have and will maintain n Certificum of Consent hp self-insum for Worker's
Compensation, as provided for by Section 39ad of the Irbor Cole. for the I'�
performance of the work for which this permit is issued. v 10
01 have and will ninon Worker's Cnmpawminn Insurance,m rwpoed by Station
3700 of the Lala Cale,for the permeations,of the work for which thispermit i.
sued.My Worker's Compensation Insurance carrier and Policy number art:
Curried - Ibl'av No.:
CIeRTIF1CADON Op EXI; 19ION FROM WORKERS'
COMPENSATION INSURANCE
('fbls minion octal nal be crn,fold It Lha permit is inone hundred dallns,
($100)or less.)
I lenity Ilial in the performance of the work for which this permit is issued.I
,hall mol employ any pen on in any manner so us to become subject es the W'mrkcn.'
Conlpenwtion Luw,of California.Dote
Applicant
NOTICE 170 APPLICANT.If,ofler nuking Ihi,Ccnifleme of Exemption.You should
M1eromc,uhj et to the Worker,Compemonion provision,of the tabor Code,you must
C) Itmhwith comply whit such provi,inm or this penult%hall be deemed revoked. '
FCONSTRUCIlON1.12NUINCAGIiNCY
5 I Mrehy aRmn that here is a construction lending agenry for the performance
W nr the work for which thin,permit is i„led(Sec NFlI,Civ.C.)
QLender'.Name
z Lender',Address
V I certify that 1 have read this application an t sial,that the above information is
Lt. F. m reel.1 n,rec m oruu,.,In all city and county orcinances and unto laws belanng
Q [) mbuild!og.onstrncllon,and horchy anthov,rcryasenhnivc,nfmi,city In enter ulwn
are ahovomcnllnned pngerty for Inspection purpwe'. .
[.. L M',)agree,muarc.indemnify and keep harmless lit,city of Cupertino aganst
W Iiabililivs.jnJgmcnt,,APPLIvoce.'vnJ espcn,es xhich may in vnY way avcrve againa said
U z Cityinunncau ND RSI NDSA of Ihi,,p,CO
SOURCE REULAIIO'NAND$AND WILL COMPLY WI"Fit Al.l.NON-MIN'1' Issued by: DLI,
SOURCE REGULN'IUNS.
Signalureofnpphcart/Comenclor Date Re-roofs
!IAZARDOUS MATERIALS DISCLOSURE
Will tire appbcmn m union,bolho,oten,am u...lot hams,b:o:nma,mtncd:a Type of Roof
a,defined by the Capcnino Municipal Code.Chapter ala and the ueahh and Safety
Cade.ecYcu 255)21)'? ❑No .
All roofs shall be inspected prior to any rooting material being installed.
Will the alndicamoe Itouromildingoccapant t.e CwipmennordeIviee.which If a roof is installed without first obtaining an inspection, I agree to remove
sir Ira.ardou,air cor aninanr.a,n,fimd by the nay Area Air Quality Management
�,Irierr all new materials for inspection. Applicant understands and will comply with
13 y" 0 N all non-point source regulations.
I have real the hazardous materials requireniens under Charmer 6.95 of the
California Health h Safety Code.Sections 25515.25537 and 25534,l understand shat
If the building Joe,nut earreelly have a)num.Inst it i.my resrypmibil'ny to notify the
cupam of the orqu neon which owl be met pricer In i,suansa of a Cenilica l of
i'Ce.,abc, Signature of Applicant Date
Gwnerm,nfmri,edage., Dam All roof coverings to be Class`B”or better
OFFICE