01010064 (2) CITY OF CUPERTINO
BUanwC.DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS
. 103SSCENIC BLVD CHEROKEE CONTRACT N9TTLtI'J. 01010064
38OWNER'S NAME: APPI.ICAI'111N SU13 ) rli
BLACK LYMAN D AND DEBRAR 1220 COLEMAN AVE /17/2001
PHONE: c408l727-9850 SAN11ARY NO. CONTROL NO.
❑m% ARCIIE FECDENGINEHR: BUILDING PERMIT INP
00
BLDG ELF,CI' 'LUMD MEC
ta•�E I_I I� t-� GI
SN j LICENSED CONTRACTORS DECLARA'T'ION Job Description
- �' I ners"allinn Ihm 1 am licensed under Orevision,of Chapter 9(commencing
O„`1-° with Section 7W(pol Division 3 of the lfvinecennd Podm,,ior.Code,andmy l icense
REPLACE SEWER
am= fullforceand l t 3 Y
1 p w .inl ClaIs_Z 4 Lic.N 7 V
a.`a`F Dam Cmnl:Ra'
F-w ARCHI'rHC'fs DECLAicnevoN ,
I understand my slam.hull h<uud as public nenrJs
a as
Limma l PrdLnsional
MC�
OWNER-BUILDER DECLARATION
hereby affirm that 1 am exengn loon the Contractor'.License Law for the
Allotting re ison (Section 70115R JP Professions Cd \y city or county -
` G wh'Lh m,os.ap9 Ito,oromf, dor.im,or.dvarohoh.o,ce,co, yo ton
we
,Tort 'I q thel
il' II i t a II b down ni t
��`° ,ba,heo.licensed pIt men .of11Conacwtor,le Law(Chapter9 Sy. Ft. Floor Area Valuation
(unmmweag w ith section 7W(lul Dv iso 13 of the Bu s
- n IProfession,Code) $m
or That he is exempt therefrom and the basis for the alleged excngnion.Any violation
of Section 7031.5 by any applicant for a lemur subjects the applicant to a civil Penalty
or not mac than me hmndrtd dollars(3500f APN Number Occupancy Type
35708036. 00
❑1.d ownerofthe all the s ru my employees in with wager le their Ile(Sea aien.
will Jo the work,unJ me.wewru is not immnJeLl lir nlrurnl lin sale IScc.7(1JJ,
Rushe's and 1'rofc sjor,Code. 11h,Cnnunemr's License I.uw Jac.nal apply(o nn R 1 ed nS C
r of pnnpcd,Who build,or Inmroven II—rod.and who ibe,wch work thatch 106 — SE f� •. �f � f�
arthrough Ito..tun employees.noticed oral such improvemems am nm intended or
o1hend for sule.It.bnxever.the building or Impmvcmcm is sold within one year of 202 — UNDERFLOOR PLUMBING
ampletinn.the nwmer.1,vilaerw;nnatemehardenarpm%ingthatwiianatbaildor 01 — ROUGH PLUMBING
improve far parfnrse of erne). ?.�
Cl 1. t lifetro,v,my w. 1I I� I i mI,I d t nam' 507 - FINAL F'LUMHING
construct th p 'I t(So,.I7(141 o J e f it 1 1Y L t morns
Iwddoesn'ttlnh - Ip Pa 'h nlll l t ,, h
and h contracts lira Lb projects witha eommet rf 1 licensed pursuant ic the
Goll t 1' nde Law.
❑1 am cramp(under Sac .H ft P C for this ry+sur
Owntt Dale
WORKER S COMPENSAI'IfIN DECLANAfIUN
1 bc¢hy"Ilion umAcr pcmJty cl Ia'rlary use of tau I'odowlng declarations: O�
❑ 1 have and will tannin a Cenilicam ill Consent Iu whl inwrc for Worker'.
Conpen.ation, no provided for by Section 37W of the L1ne Curie, for the `
peafom eve of the work for which this permit is iswii
❑1 have and will nminmin Worker's Compensation Insurance,as requited by Section
OW of the I.aboo Code.for the Podoorrnce of the work for which this pnnit is
acted My Worker's Ccf Pcm c10c Insurance carrier and Policy rano er me:
Ca-m: Policy No:
CHR'I INCAS ION OF EXEMPUON FROM WORKERS'
COMPENSATION INSURANCE
("is section need not be completed if the permit is far one hundred dollar,
IS Hp)or Ines.)
I manly shut In(hepv&I...move ur he work rnr which Isis permit is usual.I
shall nal atpJnY any vioon in my cannotat so a.m become mlbjcct(It the Workers
Compen,anion Law.of Culifnmiu,Dam
Applicant
NOTICE TO APPLICANT.IL atter making this Certificate of E¢mPtion,you should
M1ecome subjece Worker's Cummw
le (ion provisions of Inc Labor Code,you mus
Q O no Nforthwith comply with such provisions orchis permit shall N,decimal revoked.'
FM CONSTRUCTION LENDING AGENCY
!YI herchy allinn Thal Than is"con.toclion IenAmg agency for the pHbmuurec
lir line wanrk ani wbid,mop piano,is ismcd Itte,3097,Cw.C.I
Q Iende,,Name
.7 7 Lender's Address
U 0 1 certify that 1 have read this application and state that the above information is
Ix. 1.,.. ......I.,vc ton comply with all city and county old....est and nam laws mlaong
C) C.2 bl building condolence.and Intercity authorize representalse—f oris city to enter upon
J
me alrove.manli cd IF sell,to,inspection purpene..
H P.
(We) gsave, nel,randlt' alk p anodes,the L'Iit r Cupertino"4m,i'modagainst
I
V] CityiW
I' 1 p ors 1 ) nuny "y' .yuinu:ulA ,fesCity I b f WIL 'I ////SAND WILLCOMPLY WITII Ahh NON POINT Issued by: Dale �/
UUnaonpamor Date Re-rooGARDODS MATERIALS DISCLOSURE
mmtur:buildingocupamnnmorhandlehamncsin"mri:d TYpeof of
as do fined Iry Inc Ca,ld n Municip I Code,Ch par 9.12,and the Frahm and Sa Icty
CodeStool...,
25572110': _ El No
All roc s shall be inspected prior to any roofing material being installed.
Will the applicant or@mm building occupant use equipment(if devices wmlch If a roof is installed without first obtaining an inspection, 1 agree to remove
emit hemN000,air comaminanu as defined by the Hay Arca Air Quality Management
District? all new materials for inspection. Applicant understands and will comply with
❑Yes - El No all non-point source regulations. -
1 eve read the barn Ina,m leri,lt ngaimcln,m andel Chamer e.95 oI the
Clikeno lLaId t,Same,Cod"Secllnm 25505.25533 un 125534.I wd,isood l hal
it the in Hill ng due. mmrnlf haveulcaun.that it is nryre”, vihilily ur nndtymc
"ecupam of H eqm, nen(, hick owl be non Prior an issuance of"Certificate al _
Signature of Applicant Date
t wnenn mizcJ; Da¢ All roof coverings to be Class •'B•' or better
OFFICE