00120147 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
Bun.uwcAnnKrss:_:3 1RICi'IWOOD DR (m---TaINO F'LLA'J73ING 0011,0rVID.
lCk'ri.
OWNER'S NAME Y GAI IU�SUB DATE
ISL Miq DAIJID 0 'TRUSTEE 1.(X297 S Dl" AN7„A rc.V 1.21i. '��'f-,< )
PHONE. SANITARY NU. CON]ROIL NO.
(4(x)13)2W06,18
BUILDING PERMIT INTO
ARCI11'I'lil'I IIiNGINEI3R: BLDG ELECT PLUMH MECIi
FG u 1--, _I
FCyj LICENSED CONTRACTOR'S DECLARATION Job Description
`= myccn,c Ks:.IF'E, WATER SET,VICE/ CIFUJLATING S C
Business
hereby affirm m
Thal l am liceed under provisions of Chapter (commencing
mf-J wire Scction]IXNq of Division3nf the usincss and Prprofessionsc,abet
ions CndliC`
ii:
x mhnhnecanr Z 1
Om i _
Cunlrvclor
t+ 5 a ARCIII'I LC'I"S UEChARN'1(N
C�O� 1 unJcrstaml mY Plain sh:dl Fu u.wrd un public rcaeJs '
�r—
ip p LictnscJ ereby al
ven
eD OWNER-BUILDER UECf.ARATIIIN
heathy.f ^ /
1 irm that 11.eiunpl from the Conioae C License Law lin he /
1 z< whifollch
rensreasa perm(Sectit
toun
comamucL alness amt lve,der Cute:Any city or county
.tura
D which reyuims a lnrmit m ttm,wct,amp.improve&molinh,or repay any nrmure O
i3$ th.hr1%l5cenwdpuaonitothcthei%it)soff Conrermilmelca.igM(Ct,1e11Kn1
mal Wena«bind pnrsaanftome rr,innn,none cnnmmefwx ucenK law lommter9 Sy. FL Floor Area ,:- Valuation
or mat he ing wish Section ont snit e basis
3 of the alleged
mp 14nb Any
vi Gdel !G.JCX100
ormat he is csemPf thertrmm and the basis for the alleged exemption.Any vinlalion
of Scadon]031.5 hr any applicant fur n permit whjwrt the applicant b.n civil pcnahy
afmmt mom than me bandrenamhtrslssan), _ � APN Nu hber Occupancy Type
3EJ: )1304`d..(�Id
❑ t as owner ifthend he ormycntplot inwilewore,hHhtlror at,
union.
will Jct a work,and he ode On iv un inttatdW or inherent for snot ISec,],,4.
B-inan
owner n,pro Proany Who
ild%or One Cnn%thanaiere n.an nm Law Jrns urn apply m tin
-prnpc r nmxex 202 ••- L1bmE�i'FI_O(:11"iRF��.K`Ikt].hlL4ections '
toner nl o Who builds r thereon,and oho erns m n work or <
or through his own employees.provided flim inch vement is%ol arc not intended yew or
compo for sale.If.hat ever,the building or and rvement n snlJ within nee yew of 3011 — F;rnaT7.1 f-1_UI•IE<I IrU:Y
ioproverfforthcorenefs.le.rwill have the mmrden if proving hat he did net Fail)lir 5� _ FINAL F'LUNDING EI'My
lnrmv pnnpom a
01..ns owner lir me prpere.am c emsnely contmcdng with licensed comnuton to 507 — FINAL_ PUNTMING
instruct the project Isce.7B44.Business and professions Ctme)'Ihe Contractors
License Law dims not apply to an owner of prnpeny xno bund%or iteptove.smesion.
and who eommO,lin such oo,w,with u coommo r,)licensed par limn it,the -
Cnmra l,u`,License Law.
Inn ax mpf under Sm, .I{A PC I'or obi.ol.ion.
Owner Dole
WORK12R'S CONIVIiNSATION DECLARATION
I hereby affirm under penalty of Inrjmy one of the following Jectwolions:
�0 1 have and rill maintain a Ccnilicam of Consent to velf-insure for Worker',
Compeumtion, as provided for by Section 37W of me Labor Cute. for the
,it lame if the work for which his permit is i...ed.
01 hove t I will mi Worker',Cumpemation[nmmnec.as reunited by Section
7]1X1 n 'the Lanir Crde,our the Perfnrnumct of me work I'nr whlen Ihi,prnnif is
.MY W ko:.C meahe In> ea I I rel ley numlnr
�lrell�mel�1 YrNo. o� 9y
CERTIFICATION OF EXEMPTION FROM WO K RS
CONIpIiNSAI]ON INSURANCE,
('This section need not he vomplemd if me permit is for one hundred dollars
is 100)or lase)
1 anifY thin in the performance of the work for which his permit is issued.I
,hall not employ any perm.in any m:mner vein as to become s.hj.t to he W tars
Com wimilion Laws of Califoriu.])am
Aima it
NOI'ICH TO APPLICANT 11:aper mak'mg hi,Certificate of Exemmion,you nbould
bc...... m,jUf ,,the WorkupsCnnuemanin provisionnrthe Labor Co le.You mint
Q O form w,m pimply wish ouch pnrvision or fhiupermit shalt he Ju:n,'I rco'ked,
V] CONST RUCTION LL'NDINGAGI?NCY
a ? I hereby of i.m Ihit mem i,a conswelion lending agency for roe performance
Lit of he work lin which this Nouni,ieaucd(Sec.TH].Civ.C.)
0. Q lender's Name _
z Lender',Address
V Q 1 minify that l have mad this application and cam that the above information is
li F correct.1 agrtt to comply with all city and county ordinances and.stale laws relating
Q U
In building construction,and hereby uifhirm representative,ofhis city inn enter upon
ry the above mentioned property for im,moian purposes.
F d
(We).,me m save,indconily DTII keep harmlr_s,the Cityof Culnnino agoiina
Vi Iinhilllica,bdpmm�ts,coots mol cxpcnxe.a which may in any wxy xmnK ngnin,t sxiJ
U Z Co nm tem .ifmlln gntming lir ami.lKnnif. 1� �1_(�(�
I''LIC Mf 1N 'RST SAND WILL COMPLYWITHALLNONI+tyIN'1' lssuedby:C4��j Date
14 Z?• J
sigrano.e of Applicanl/Contractor � .Date Re-roofs
HAF.AR1y(yUS MA'I ERIA1S DISCLOSURE
Will five applicant or mom building occupant atom m handle limanxme maenal Type of R f
a,defined by the Cupertino Municipil Code,Chapter 9.12,and the Health and Safety
Cole,Section 25532(,)? '
O Yes 0N All roofs shall be inspected prior to any rooting material being installed.
f W111the applicant ortmore buildingoc,u,wduor myourniorde"ce,w'nicn If a roof is installed without first obtaining an inspection, 1 agree to remove
emit h oardous air cinmminanrs as&fined by the Bay Arca Air Qwdily Management
District] all new materials for inspection. Applicant understands and will comply with
0Ye, 0N all non-point source regulations.
1 eve read the ha<ardnn.s tmned:h rcyuifantms under Ch:4mmr 695 of the
California Ilydlh `Safer Crate,S vniom 25505.2 533 and 25534. unJvxmnd Ihn
it n don not currently have a mount,that it is toy m,, ibility m noodyfhe
I tpom of m re mems whim nm.0 he inn prior to issuance of a Cenificme of
'Z��Q O Signature of Applicant Date
I sir aamnrt< cot Doc All roof coverings to be Class `B•'or better
OFFICE