01020006 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: 1.07/010 STEWNYS r IYON RDL74-RC1RELE COMI-VIC' W. 01.02000E
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OWNER'S NAM a lagl:l INVI_f]I CR G UP I_11,11i YI l:-D 12.,2eJ ul�l�nlf�bl f�l AI'I'LICAII(1N SUI)SlnlFafJC��1.
a� I'IIONE: (408) 727•-'.)8Na SANITARY NO. CON TRUE,No
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Z AI1CH[PiClAiNGINIER: BUILDING PERMIT INTO
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'O y 2 LICENSED CONTRACTOR S DECLARATION Job Description
O y m o I herenv affirm Iha,I art lice-0 under so—i.....of Chapwr 41c...m cncing
wishScainn 71p0)n1'Uivision 3nl',he Ru>incs.anis 1'ndosiuns G,de,anis my license cA:U.T; C' _FRq OUT INUR-LATIMI
6 is in toll force and.fico 9
i s w` Liccnce Cl u..C. (�CS�u2. -ic.p—.3.I6 LT
K O a Data�/Z-/22(Z��— C.n;,Imnor_ -
u 3 u.io ARC10T CT'S DECLARAI I N
F=NO? I understand my plans%hall he,used as public records
w L p p IJ......d 11..ional
OWNER-BLDER DI:CLAR61'ION
ec o� UI1 hereby affirm that 1 in emnnpt linin the Con Irace mr'.License Law lir me
F-G i
ll ,Moron
foemn .(Section 70)1.5,Ilaoncne and professions Code:An
2 Yciytnr crante:
F F ea wnirM1 its iss n n e.also te comlrnn,alrac improve,Je c....p,or repair any allelic
n3z [aonoh.censed r.elwre to TheTbeapplicanl fns Conowbe,o]11msLa.( anenem
cone is brgwitpSectio Mme art Division The Cmnm,i.c,,License La.(Chapter Cor9 Sq. Ft. Floor Area Valmr�ipg'p,�
Icontrol Thaihes eaim SectionMEET)ad Division orf the 1 isms anis iop An,vi Code)
or mm he is cxemp, an up,h and,nu hods for the,s the
J ,dh,: II to Anis vioimion
o1 Sof oun e than
LS by any dred dam urn a IenniT whhjeds the npplle:mT rah n civil Iwoalty
nfnmmnr.canrvennndMddnllm.(s51Xll. APNNumbe`�Kr56030'r+B.0%10 Occupancy Type
❑L as no,of the property,or at,employces with wages ns mei,sola compenmtian,
will do the work,and the stmruua is not intended or offered fur Nile(Sec.7(94. W
Ilu.inca�and Profe�wions Cade:Ise Conunemr's hicvnse Law roe,.not apply m an ,1.0f 'Rc9yiWI'.YC nCr-iVI-ITT"R
r of property Will)builds or improves, mcon,and who docs such work hlmmlf
owner
his num employees.pMvided,bar such in,pnwemems new inn infrared m ? J
offered far. e.ILmeweee,.meholding ,,impMm
eceafis oldul,hinaneYearor - UNDLT.9=L.LlClfi F�LflIB:[IICT
w
Lannpleti..n,me(wner-hnildcr will base 0n,hunlcn of proving that he did not build ar 30:1. - 1@ 141 F'L-Lll'I 11,16
nprovr Int purpose afsole.).
❑1.as nwnc,of the pnrprny,a.esclusivsly commning with licensed connector,or,To - 5PTZ -' 1=I,Nf4.. 1=9_ RIBING
Lmga,the proieo Isco.71,14,HU-11111 and Pnde..iana Codo:I'Nr Contractor,'
micense Law doe.no.apply l..no owner nl'po p,d,wI hullo o,improve,thereon.
and who contracts for such projects with a aourra (H licensed pursuunt M the
Contractors Licentt Lrw.
❑I an exempt under Site. ,B G P C far mi%feasan
Owner Date
WORKER'S COMPENSAI ION DECLARATION
hemny will nmdcr a Ceofperjury onesetheoself'ing Jednmt lone:
❑ I have anis will maimain a Is,Sere of 37M of nr%cLabo,re for WarAche
ConnivN,f..i anceo. he work to, for hY Section 37fq of he Lvhur Code. for the �!
parfonnanre nf the work lir which this ihennit i..issued.
01 have and will maimain Workers Gnnpenmdon Ina.rmce,as revealed by Section
8700 of the IaMnr Code.for be perlbm,ance of the wank fur which,his panni,is
ismed.My Workers Cnmpensmion Insurance currier Dad Policy numher am:
A � z:n
CEiiii6�te rttJfG 7/
RS
COMPENSATION INSURANCE
(I Ill'soctioa need not he ramplmrd if no peh nil is foram hundred d..11ts
61 W)or It
1 certify that in the performance of the wod,lir which this permit is issued,I
%ball urn maple,any Is,non In nay%tanner nn it,rah beaene subject to he Workers
Cumpma0nn Law%of California.fine
Applicant
NOTICI!'IO APPLICAN'L If,she,mukin,flik Cenilime of11 eminent you should
Income euhdevn m the Worker.Cohnpm
earion p ov.,ion,or or LuMr Cole Yon mus
Q O fonbwid,comply with%nth,....%ion.or Ihi.Ienui,%hall bo donned revoked.
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CONSTRUCTION LENDING AGENCY
a ' 1 hereby anion that there is a cunamnien lending agency for IM1e perfomhancc
of the wad lied whidT lbi%pcmhil is issued lsu.91197,Civ.G7
L Q lenrcrr Nnmc
= Z I<nreA Address
V C 1 cervi I that I have read 11,i%it,hNelon and etre Thar Ina above infonnnTlnn is
fit [: c. lis" I ngmc Is Onnply with all city am ouun,y....inance%;are date law%twining
Q U to lruildingoon.uuc,inn.and hereby aumn.im nepresentmives of Ihi%ei,y,ounce,upon
} W the aMn'en¢ntioned p.,,oy far impection purposes.
L., y (We)agree to sine,indcnmify and keep hanaless the City of Cupeninouguirot
L (n liabilities.IudgmrnT..aoa..and captor%whsh may In any way:.acme..aiu,l mid
Z, City in eon.wquencc..I,he gradingof this lonnit.
SOURCE REGUI.WiIONANDSAND WILL COMPLY WITH ALh2N �/ issued by: Date
ura.0 pplhr t nuamr Dara RC-roofs
'.ARIIDUS hlAl'EHIALS DISCLOSURE
at Will Thu applicant car future bu'ddins'ccapant.a.rmlinage haadou%n,aerial Type of Roof
;is defined by the Calwit no M ,ieipal Cure.Chapter 9.11,and the Health and Safety
Cade,Suction 25532o04
0YpS No All roofs shall be inspected prior to any roofing material being installed.
Will the appneen or Rnare banding occupant use equlpmced or devices which If a roof is installed without first obtaining an inspection, I agree to remove
u
emit huaunlnu.an,enu
mminao s as defined by The Ray Area Air Quality Managemem
all new materials for insjlectioo. Applicant understands and will comply with
❑Ye% INC all non-point source regulations.
I have read The ha,ardoes mceriaN requirci ems under Chapter 695 of the
Calif..nia Health h Silly Cute.Sections 25505.25513; d 255.14.1 unJcoAL I that t
if,nc building dies nm currently have a rearre.0ct it is my respnnsihild ,o notify the
occupant of the requirements xhich mast he met prior M issuance or a Cenife0c of
Oce.par _ Signature of Applicant Date
�-z ZOOS
DateAll roof coverings to be Class"B" or better
her ar auma int
OFFICE