01050130 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDJU ''5 STEVENS CREEK rr ND. 10501.50
OWNEWSNAME. HHIVIIVILLL I-HIJWtill DIVISIONS FREE 11PLICAI'IONS1,05 r114/: 001
PHONE; (408) 379-0400 SANITARY NO. CONTROL NO.
0--. ARCHITECT/ENGINEER: BUILDING PIiRMI'I'INIeI
O_F il.l ELECT PLUMB MECH
U`j .I -1 IJ
to<
oz LICENSED CONI'RACrOR'SDECLARA'uON Job Descri 1011
1hctnhy affirm that am Iicen ad under Provisions of Chapter 9(commencing WEND INTERIOR P RXIXIONS.
-a-tw wire Seen....ya)(bot on d.111111 euSme.. Ill VI r,.IIIa.Colµamt„Iy rear.
is in full force and cffitn�
w¢ License Class
p Dale camntennI,/T�fGe/1dC� -
w" G+a ARCHITECT"S DECLA ATION
t O I I undcrslan l my plan,shell Iw need-o puhre records
tiS p O Licomed Profcseinnad
x oOWNHIR-BUILDER DI'.CLARAl'ION
1 hereby vfrrm that 1(m canon from the Contractor's Licemc law Im the
Z>' billow ng reason (Sec tinn]WLS.Bupincs-und Prufe,,ionx Calc:Anyclly or county
cex C wh c8 eq 1 nn t I o f ate lop d lid mp ;Illy mivauu
i 3- pritrt t alx y ' 'lh pl'li tf hpc lits fl -tgncd oat nem LT.
that I I urs a I t Ih ru th C t n/ 1 I (Chnpler9 Sq. Ft. Floor Area VaI0515000
(I tom ism,with Section 711081of DEision Sof the Basin,,,unit Prnfe.dunx Cale)
or that he is exempt the of an and the base%for the alleged exemption.Any violation
of Seclion TO 1.5 by any appllcen bell permit'abie"'the appliaotl in it civil pemdly � .{s
ofnm more than five handled dollars(SSW). APNJaS"toiir'094. 00 Occupancy Type
❑1.a%owner of the property.or my employee%will,wages(s their sale unnpensmion,
will ns 1M1<work,and the structure lliis not intended m m,Law for%ale(see.7Bm. NO ASS I GHF-Pir(MOPEtTlI ONS
Bm nnJ Profen s Cores Theis n t sten d or o ened Jocs rat(Spey 0 a
r of ppcny Who builds or improve lhcrean,and who does wall work h..nwIH
or, mthrough his own emrloyecs,provided that such improvemems am not intended or
offered for tele.II:hawevea the building ur impma,is sold within nae year of
<mmplction,thc.mncr-builder will have the burden of proving That he did
nut build nr
improve bar pro %outod )
❑I ,,the P pens luso x ly centracting x nth licensed contractors to
,onaroclII tr Ica(Sol. N env. I I f .-ms C I )Th C tr te
LicenseLa -d not apply t neo f n pane h,builds p %thereon.
and 1 contract,% L rich
p po .J is t I. x I real licensed ptirwanat to the /
01 son em License See
❑1 vis exempt under Sec. .B R P C bond,ream.. Q
Owner Dee /
WORKEWS COMPENSATION DF.CLA RATION
I hereby uffmu under renally Illperjury one"film following dcclmatinns:
❑ I race and will nnintain a CYmilieam of Cnnsnn m sd ouroure lar Worker's
Con,pcnwtion, as provided for by Section 37W of the labor Coda for the
pnhn'nnnac of the walk bur clown,hie rennet i%I...red
❑I have and will maintain Worker'%Compensation Insurance as required by Section
3710 of tire Lubar Cock,lot the pcd...trance of tlw walk leu which his penult is
issued.M W it Compcnsallon Insurance earlier
r and Policy
number am:
Carric��-�_Policy Nu:'�
CC:RTIPICAr1uN OF EAEMPr10N FROM WORKERS'
COMPENSATION INSURANCE
Thi,.Conon need er be I iple al if the pcm,il is formal hundred dollars
IS I W)or less.)
1 earn that In the perfu unlace of the work for which this permit is issued.I
shall not employ any person in any manner so as to become subject m the Workers
Compcmmlon laws of California.Doc
Appeicunt
NOI ICH To APPLICAN'C II:after making this Certificate of Exemption.you should
became subicet m the Worker'%Comlcr ation provisions of the Labor Code,you must
Q O limhwilh comply will eueh Pruvininns nr ibis penult 11-all he donned ne—ked.
z
CONS I themis aeon LENDING AGENCY
I weak
for alBnn this Them nes....amnion lending agency for the perinrmunec
lata nfine work for wM1ich this pennil is iewcd(Sec.3W7.Civ.C.)
L Q Lender'%N(ne
LenJcr'n AJdrass
V Q I cenify me 1 have read this Application and state that the above i dollual all is
correct.I agree to comply wino all city and county ordinances and%tate laws relining
Q (•J Io budding.nnur.nlnn,:ntit hcrcby;nnborlaorerraaularl%cs Ill this chym Intel plan
the aMwe.tnnnimtw property for inspection pmryso.
(We)agmen,na,a,jorhamifyand keep harmlms the City of Cupertino against
r fn Il:mililics.juJgtncm%.coos trod capita,which-nay In any way untrue ag:hno.said 5 -0/
C.7 z City en nmxymma of the granting of this permil.
APPLICANT UNDERSTANDS ANO WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS,
Signature of Appllcani/Cmmunnf Dile Re-roof'
HAZ RDOUS,MATERIAIS DISCLOSUIIF,
Will the apphca.to.mwreb ldingpan-pan omeor handle haaa,am%mamdal Type f Roof
n datimvl by Ito,Cu,marorn Muneiphl Calc,Cbupm,it and Ili,I leallh and S-duty
Cole.Section
on 255326(0' N
El All roofs shall be inspected prior to any roofing material being installed. .
Will moa,licam or future bwldmgoecunam use equipment nr devices which If a roof is installed without first obtaining an inspection, I agree to remove
I n
in hamrd.....air cI latr n:me as defined by the Bay Area Air Quality Mmmgcment
Di.(dalo Ye ❑Na all new materials for inspection. Applicantunderstandsand will comply with
all non-point source regulations.
I have mad the humrdous materials re,mramems under Chapter 0.95 of the
Cahill.....a Health N Safely Coxlo,S,c ions 25505,25533 and 25534.I understand that
it the building docs not cmrcndy Lave a mount.that it is Illy mspon%ibilily Io nobly the
-cannot of the reyuiremens which masa be mm point to issuance of a Cer ificum of
° Signature of Applicant Date
f
b} 7 llny)p 514 61
r ,atnborold agcnl Date All roof coverings to be Class "B” or better
OtterOFFICE