00100166 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERM r NO.
R - - CT �w ter 00100
OWNER'S NAME: tills. APPLICATION SUB DAP I?
, _ 10/25/2000
)NE, ")I•t SANITARY NO. CONI RRL NO
I
KZ ARCHITECT/IiNGINIiIiR: BUILDING PIiRMI f INF,
O C ❑LUG IiLECT PLUMB M[CII
d
LICENSED CONTRACTOR'S DECLARATION Job Description
o 4 z I he,en affrin mar 1 an,licensed under n.of Chapter 9le rrome.in
z > prnvoln p g
F"C� will 1Sec.11f n]Ixall id Mao.
e,
0usins,x,and Prof esaian,Code,and mYfronw
e,ai Y j is in full,arae nA cliccl.
g-,6a Licemecm„° Lia.a SHAKE TO COME'
%%o i D Dae Contmam
W 3 2 N Alh HITHCI'S DLCLARAr1ON LXPiRE
Ounden,andnay plans nlwll M1e lived a,puddle record,
LICCrtMJ Professional
a'g LL thatIn arwaqu OWNER-BUILDER DECLARATION
Como ON
1 hcmby,(diem that n, Ravine Innn Ida CnmruaC'.,A Any
Law far me
t 7¢ which ng reama,permit
to co LA Basinos and r Prot demob h,or Any tiny or county
e
`der four
carry pe in construct, t demolish, M Y.t cum
amaJsm lhnl e I L,ur l th "i optional M1(ar IIm1I b J.Ch¢nmm
mwI o, : 1p o t d p io 3 t t Inst Low Iceanter) Sy. Ft. Floor Area Valuation .
(what heeI,a wim Sttrinn om and
Division 3 01 me Business a,end I'mrcay ci Coda)
ar that he is e,empt rherefmm and or kens fm Ido alleged emmant ill Any via natty
of no, 7031.5 Iby any applicant for n pcnnil.,unjccds IM1u applicant m a civil penalty
at Imre man live bombed dollar.(s500). APN Number Occupancy Type
1.as�wner nnhe property.rte mY omplayces with wages as their sole comnenmtion. —.
do the work,mW,he nmomm i,not intended or offered for,ale(Sec.7(94. -' •'
w,maa.and Pat...iom Code: Me Contractor's Liecn,e Law does an apply o as Required Inspections
or
of pm,ny Who build,or improve,Iheoon,and who does such walk himself
or though his owa'employee,,prokled that such improvements are not intended or 305 — FRAME
thered lar pale.II;however,the building or Improvement it old within one year of
,mplafm,.ma nwa<r-n.ildar will baveme hatdenor pawingd,al hadal nal m ildor 307 — INSULATION
allows,for PURane of sale.).
601 — ROOF TER, OFF
[Jlas owner or nae lnopany.anal e,muslvely contracting with licensed Ammtanom ra
,m.act me protect see.7014.B,t.ina,,had I•a,ms,lom Cede.) line Contracmrs 602 –• ROOF' PLYWOOD NAIL
License Law d«s not apply to an owner of property who hulas or improve,mcram.
and who conowl,far such project,with a conswors)fcxn.ed paromm,at me 603 •` ROOF BATTENS
Camracn,/t License law. -
❑Iata it, Bd
xPCli,t ,lno.o 604 — ROOF TN—PROGRESS
Qwaar Dale ^^�X`)`)��
KBk'S 'UMI'IiN5A1'IOwCCLARATI
Q
I hereby.Minn under pcmhy of Perjury one of me lldlowing dealmol ora:
1 have ;rad will maintain a Certificate or Convent to self-Insure for Worker's
mnper,ahow, at pmvidnl t'or by Section 7700 of the Labor Cade, far the -
Ierfamwnee of he walk lot which this permit is i...ad.
❑1 have and will mainmin Worker's Campcns;nion lmumnce,a,reyulred by Section
170011'tire Luton Car,.fur,he wits,aeal,a of the work lot which this permit is
seed.My Worker's Compensation Insurance currier and Policy number me
C'nrria,: Policy Na.: -
CI?RI'IFICATION OF EXEMPTION FROM WORKERS'
COMPE:NSA'1'ION INSURANCE ,
frhls section need not he completed if the penal it far one hundred dollars
WI(XB of Ic.J
I ccnify Ida in the pchwarroa of the work Ln which this pedril is issued I
shall not moploy any parson in any rammer or as to became subject a,the Wadcrry
Cominamino Lows of Cul,li,mi..Oole -
Anplicmt
NOTICE TO APPLICANT:It,after making this Cenifica,or Exemption,you shmad
beeom.sunlcc,mme Work,,,Cnm,ra,a,hm oivikimn,of the Lahnr Cuda.Yo.moa
I'mI,.hb comply with watt oarkin I, ,1 m.,pennh,hull be dwoord revoked,
F = CONS'FRUCTION LENDING AGENCY
1 hulehy union,mat mere is n conwumion landing ugenry for the pa fo mane
nt'tire work for which his tenon i, „ns,d(See.3097,Civ.CJ
Q Lender's Name
Lender',Address
V 0 I candy viol I have read Ihin,pplicallon land state Lha,the all morriation is
k. t.., corms.1 agree In comply wim all city and arwW ordinances and.Rate law,relating '
I, mb,ilddngem,nonaion.and hereby uvlborire representatives of this city menter upon
r� the nbovaanent toned pm,,y for ar,,cram palpown.
L
(We)agree tosave,indemnify and keep hurmdess flue City of Cup.Ylinn 4',11.,1
Fy liabililia,,judgment,,costs and e,pennen which may in any way nteme ugoina paid
UZ ChYln cons"N..
hds pennin.AVI'LICA LCOMPLY WITH ALL ON POIfJT ISSUCd by: Date
SOUNCE Siamntmo �� Re-roofs
I IIALS.)'CLOSIIRL
Will the nppfcWn is mom ould'ulg o,v,pa It cola m donate moardua mental Type of Roof
as.defined by the Cupertino Municipal Code,Chapter 9,12,and the Hcalth and Salary
Coda.Section 2553200?
G Ys,, Rw, A All roofs shall be inspected prior to any rooting material being installed.
Will,he uppI cant or future building accupind use e0uipmen or devices which If a roof is installed without first obtaining an inspection, I agree to remove
Emil hamIJom air cantaminunt a,defined by Bay Are.Air Quality Mawgcme rt
,;,,,,;,�,/ all new materials for inspection. Applicant understands and will comply with
❑Ye, )(No all non-point source regulations.
I have read the hueardoux material reyuiremenu under Chapter 495 of the
C.Iifnrola e
Health A Solely Code.Section,25915,25533;nut 25534,I understand that
if the hulldiag dos not cumntly have n tmmn6llet,it No,re,pmnibilhy Ice nntiI,the
ont ccupaoft yairearan hich moa be amt prior a,issuance of a Cenilicate of
occupaAna tQ YCM Signature of Applicant Date
ownrrm uam All roof coverings to be Class"B" or better
OFFICE