01040116 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING AOUR ESS: I'ERMnNO,
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OWNER'S NAME: APPLICATION SUB DATE
wF=TnT TnHKIC;nN 45-300 INDUSTRIAL R #4 04/23/20101
PHONE: SANITARY NO. CONTROL NO.
M ARCHITECDIiNGINEER: BUILDING PERMIT INFO
Cw OI- BLDG CLEM PLUMB MECH
feed
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LICENSED
Z mp hSEUCONTRSDECLARATION
Job Description
I heresyaionthn I our f tdunderpnwisium'ofCM1per Y cnnune
:14 1- with Suction9(1Wlnrliv,lnn3of he m license
is in lot]force and el.
,oaj Lieem.,u I: ue.a `�"� 9 = REPLACE 60, 000 FURNACE
ia. Comvnm_
.u.C RCIII IECr'S DRCLARAI ION
I undcr,e,m my pluns,hull Ne mcJ m public record
; r= EDi E p O ,acxmJ Pn,Ie„ionW
Xz OWNER-BUILDER DCCLARArION D��
WZLL Ihereby.(limn Ilio, 1. exe Isom me G,nuns Coie:Anyctyor for,he 2 7 2001
Fe,Z< following remon.lseem,o ADI S•Rumness and nes dr isms h.or Any city oricounty lum
ASO whichrcyuisu tie.ionalso acums[tic uhcq impm,ch Perm,h,ore a siir gwirytatement
e'. bad to its issuance.aeromm ,,hetheapplicant lothe sucCoupeaue License
Dr.ed am9 &I
bad the islicensedwd Section 70he of Division
he Brim,, andPOLew(Chapter...Cd ) BUYL V�pr grCa VaIUah011
orfictthat
ANNAofebasin3olhaleed exemption
res Any nilmel V NNG
or that h..i,exempt Iheefmm z and(fit, heel,for the allege)exemption.Any violalon 9
of not mo 9113 n iv my hundred
oll ror n 500).11 sobjcax Ih<a551icunl In a civil Penndly
940
of not more than rive nntemd dollars ls5001. APN Number Occupancy ype
❑I.as owner of the properly.or my cmploycus with wages m their sole compensation, n�.
will Jo the work,and the urocmm is nal intended or offered for sale(Sec 9111).
90 1 A 140
llmine„and It I ..iota Cndc:'rhe Cmmnlcmr's License Law does not apply to an Required Inspections
owner of pro sexy who build,or improves meant,and who does such work himself
or plough his own employees.provided mill,mh int5nmvement,nam not unleaded of 301 — ROUGH PLUMBING
offered for sale.It.Mwevaq the building or improvement is wild within one year of
impletion,the nwnar-builder will nnve the Maden of proving than hedid n(,,Indictor 303 — ROUGH MECHANICAL
Improve ba puspme of sale).
❑I,a,ownerAAflue lnopel,;nnuexnuielveonlmrhngwith licensed<omoemram 304 — ROUGH ELECTRICAL
,nswet the project(See.2014.Business and Prole„lith,Gude:)The commeers 505 — FINAL ELECTRICAI_
license Law cite run apply to an owner of property who bodies or I mproves,hcrc,n,
anho canimCIli,r such projects with:t commai licensed pursuant ro the 507 — FINAL PLUMBING
Contractor,License Law.
Cl Ism e,vmp,under See. .B&P C ea this reason 508 — FINAL MECHANICAL
Owner time
WORKE R'S COMPENSATION DECLARATION
I lmmby nllinn under scruity of fegary one of the following tkclam,ions:
❑ I hove and will an :In a C111111Oac of Crnuen: a self.iastie far Worker's
Compemaraw. to. proomed for by Section 3900 of the Lahm Cale, far the
Isrlbur of the work for which,hie panni,is Issued.
d will maiumin Woder's comprnwtinn Imumnca,n.,equined by Scmion
391h)of de Inbur Cale,Ibr the perfi,rmi nix of,he out at which his permit is
untied,Arstarke^rs,C,omproxaion Insurance carrier and lPolicy number afire:: �
Cnrids�Jy-Yl-a^`e+ry Policy Nn.: w� •»_
1. 911 ICA'rIQN(ll 13XIiMPIION FROM WORKERS'
COMPENSATION INSURANCE
(r a, ,lion need nut be completed If the pe,it il is for one hundred Jollorx
(SIM)nr less.)
Iceirifyfliatinith,Pelf f Ili k f h thispermit J.I
shall t PI Y Y 'r � +'1''W Ars a
D
'ICI I O API I A l C k ion C i t , f 1, i t' y 'h IJ
�. become unh r.c Rn. t p (if the 1 at CW y dist 2 3 2001
DO fnrlhwnm ungtlyIlh snJ Srms ,nn-Ih'x lirnlehull laJm,mJ nwokvd MAR
z
CONS them is a con ouctioIXN 1NGAGENCY
gapar
} thereby affiran Iliad iso nied(Se 0117.Fagency lie the Performance
Lea a wort.ror which,his pennil ix issued(Sec.31ND.Civ.C.)
6. Q Lenders Name p
.7 z Lender's Address Y
U 1 cembe that 1 have read this application and state that the above information is
correct I agree m comply with all city and vanity omma,rex and„am lawn relining
f> to building construction.and hereby uuthoriec representatives of this city to enter upon
,be aM,ve.menuoned pmpcny for inspection pur n c,
E... 0. We)agme It,save.rumandfy and keep harmless the City of Comerino Iguana
UZ Ilabilitia,judgnwms,coax and expenm,which may in tiny way accrue against said _
Z City in eo l,eyueuee otic grunting ul'thios penuil.
-” APPLIOURCW .R AI. AND WILL COMPLY WITH ALL NON. Issued by:V �� /��/����CC ' Dale
� �
nor ,\ p—I nn,memr Date Re-roofs
I IA9,ARDOUS MATERIALS DISCLOSURE
dI 1c applicant or future Funding occupant sane or handle hsm,doox mamrial Type of Roof
n datln"i by the Cupcminu Matieipul Cndc,Chiron 9.12, rud,he health and SUI'ety
Code.Section 2553201'(
0Ves ram- All rools shall be inspected prior to any rooting material being installed.
Will the applicant or l ume buildi ng occupant use equipment or III ices which Ilia roof is installed without first obtaining an inspection, I agree to remove
un,humidor,:lir crnmm,hramx'1,J�md by he Buy Area Air Quality Mawgemem
District? / all new materials for inspection. Applicant understands and will comply with
Ove El No all non-point source regulations.
1 base read the ha,mdnn,n rials aqui lino under Chapter 695 of the
California Ileahh A Sam(y Came.Sections 25505.25539 and 25534.1 and enend the
if the huilditg die,not comically hie o count,than i,is my e,ponsibifity a,ramify the
cupom ol'the m Mm , I'
male re nc
weh ., be me'plot In imale M n Ccnilica a of
(kcup n
Signature of Applicant Dale
Droll rvsd.,cut / Dare All roof coverings to be Class "B”or better
OFFICE