00120158 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
'l.">•:t— STEVENS •-4.111 DL.VD (304-4,1014 INC OW)1. U158
OWNER'S NAME: APPLICATION SUB DATE
I 6100 CIUSiTD:1 LN 12/ 1,` F.l(ilfc)
PHONE: SANITARY No. CONrROLNO.
n C O ARCHITF.CIUENGINEER: BUILDING PERM]r INFO
❑❑ BLUG ELECT PLUMB MECH
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F N`° LICENSED CONTRACTOR'S DECLARATION Job Description
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z=Q 1 heresy alfnm that I urn licensed under pmvsIm of Clwpm 9 connneneing
mF 9 woh$ccd...70mBnfDiv'oionJol me Ensiaxstnul l'nduuinnn CnJe.mWmy liccne
x ismronrismeamaeBcet. q- h'^' DEII(7L.T.'TION OF FIfE STATION
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OWNER BUILDER DECLARAIl(lN
tYil I hl a ran that 1 am emmpt from the Coutmctnr's License Uvv for the
t;b a ti,llowing mit+oa(Scainn]BJI.5,Haniness and Prefesvinm GNc:Any city or county _
S a wheh re(joinvIn peralnt locl.adic,an,anne,demoli'll, I yarnemm
3$ prion t : Isis Y thel b ,nor t bledsigned:tatemen
teeth licensed Platinum to the Provisions of tire c t , est e a Ir (chaper9 Sq. Ft. Floor Area Valuation
(commencing with Section]Riot of Division J of the Bun nen,and Profen.ions Gdm
on that he is IIPI Ihcmlion+und the basis lin the allv,d cxc...,1 a 1.Any v'tolia 1 ,j O• i
r Section]U3I.3 by any applicant lin a pmnit subjects the applicant m+a civil penalty
of no,mom man five Immolated dollars($500). APN Number Occupancy Type
°I.ascof the pmpt,o,o my employee with wages as Thei r 1.11cc umhponsatiOn, - s:)
will do thewmk,and tnc vmcture ie not intended or offered lin sale(Sec.](NJ. " '
Business and professions Code:The Contractor'.License Iaw does not apply to an Required Inspections
owner III property Who hailds or improvesthervan,and who does such work himself
Ill 1111011,11 his pY oddd , p venteavane T I int,nuldin
1,10 AIa.13ILfT TEf FCTION^,
offered f It, the bidding p t is old within carey.,It
completion,Th nIwo illi
the burden f provingthat lAJ notbdm or
larprove 101 p rpt: or sale.).
O I.as owner ofn pro,pedy.ant exclusivelet o g with licensed a beam it,
.tru t at p j t(S ]IW Business d professions C m]The L tractor's O
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,cc Low does not apply it, m I property 1 builds or improves mama)
aa�0m mpt 1.]Insnnmufor r such p
Pntl: 'Ili t t 'GI li his m 1 p rhal
m
Contractor',License I.aw.
❑Tunnunder Sea ,B&PCfee thin mason
Owner Date
WORKER'S COMPENSATION DECI•ARA1 I(1N
I hereby allinn nn let pemJty of fe ury oncol rho Iullowing dcelannions:
• ❑ I have and rill maintain a Certificate of Consent bt ulLirexm for Worker's
Compensation, as provided for by Section 37M of the I.absn Cade. for the
pertonnanecal the work Ibr which titin Ienntll is Issuer
°1 hove and will maintain Worker's Cmnpnsation Imurence,as required by Section
3911!1 of the Labor Code,Int the attrac tmac of the work for which this permit is
ucd,My Work...Con htwmlmo ca,III,and Policy nutnner ore:
l�
Carl Policy No.:
C:H I IPICAI ION OI'li%EMPI'ION FROM WORKIES'
C(1MPHNSA'1'ION INSURANCE
(This ,all.owed not ba vnnplasd if the permit is for one hundml Jolla, -
($100)nr less.)
1 certify that in the performance of the work lar which this permit is issued,I
shall not employ any perNm in any human,so as to become subject to the Workers'
Compensation I.awn of Callforma.Mad
Applicant
NOTICE TO APPIACANI':IL alter nuking this Certificate of Exemption,you should
hrnme subject to the worker's Cotnlxnsaimn provisions offs 1rM,r Calc,you must
Q O Ibnhwilh cnn+ply xim such pro mhuhu nr this per nd shall he deemed revoked.
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E' CONSTRUCI'ION LENDING AGENCY
a > I heresy wdffirranhich Jul,tunm ix n c,,,,d( ,c. ]ending ageay liable prfnrtnanee
of the work lin which this permit is issued ISeu.lfyl],Civ.CI
0. lender's
Name
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Z fenAddress der i Address
V 0 I cenit'y that I have rend Itis applicuil and onw that the above information is
correct.I agree u+comply with all city and county ordinances and state laws relating
fJ to building comlrvetion.and hereby indicators,representatives of this city Rr emer.Mn
iy the above-nolaned prep rat ++epetiun purposes.
It' ems.uve.' uld vyend kchih main an ;I of Cupninoaga id
4 Z Cini
ants. :red expenses which may in any sexy accmc apninnt.aid
U Z Cr gmming of this pemnit.
A (ANDSANDWILLCOMPLYWITlALI.NON.POINfIssnedb Date
S )NS. A_ / - - y.she RCaractor_ K!/V `(/� Issued
� Re-roofs
HAZARDOUS MATERIALS DISC],OSURH
Will apPherll n,loomI Iddr,oc, not Hmmn,hanAo nwy,dme•material Type of Roof
as defined b the Cupertino Municipal Code.Chapter 9.12.and the Health and Smely
Gds,,Serf m 35532(a/'t
° nn El No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or fidure building accupal not equipment(It devices which If a roof is installed without first obtaining an inspection, 1 agree to remove
emit hvvdous air contaminants as defined by the Bay Area Air Quality Management
)idlie,r all new materials for inspection. Applicant understands and will comply with
°v°° r No all non-point source regulations.
1 have r J the harar materiah requimmens under Chapter 6.95 of the
ia�,
iu He h A S,tl y c Smtions 255(15,25511 and 25514. undemunJ that
um neno+ mr dy ha . ygyyt which must be met prim to issuance of a Cenmcate of/ � iSignature of Applicant Date
aama ea ea. - — C ,e All roof coverings to be Class `B" or better
OFFICE