08070068 REV1 w
pEgNIIT NO:ogo�oo68
.0..011115 BUILDING ET E D;0613012009
011
CUpEgTIN� TBD_TO BE D DATE ISSUE
CITY OF CONT�CTOR
PHONE NO:
BOW DR UMB
SS: 21600 RAIN ANN C ECT PL
G ADDRE Y AND PIA YL EL
BUIi.DIN V. LAU LOUIS Fp; BLDG gCIAL
-'R's NAM ING PERMIT IN �` CoMME
O` BUILD ESIDENTIAL
4083489963 TION MECK GE 663'(vACAI•iT
ONE� CLAW
OW NERDS PH NTRACTORIS DE 4,219.25 GARA
ICENSED CO VaprrWN:NEw 2 STOP FENCEryTE ISM0DgY DETAIL ON
L
❑ Lic.# 10B DESCMO PERMIT NEN MOD y SMNF W ALL&
Date T NO EMO
REVS
License Class of Chapter 9
LO
REMOVAL.
r the provisions .Hess&professions MICF OLA.M FOR GIRDER
Contractor licensed under 3 of the Bus'
affirm that i am X000)of Divis'p° effect.
I hereby with Section
commencing license is in full force an following two declarations:
( and that my of per
one of the worker's $500000
Code a enalty self-insure for for the Valuation:
affirm under p of consent to e Labor Code,
I hereby maintain a certificate 300 of th
will m for by Section issued. for by res: Occupancy Type:
1 have and rovided it is provided Sq,Ft Floor A
which this perm Insurance as P hich this
Compensation,as P work for w work for w
of the worker's Cornpensatio anCe of the 36638012.00
performance maintain erform ApN Number: 'TED
d will m Labor Code,for the P ST A
I have�r►100 of the pgK IS NOT
Section issued. gTIFICATION above information is IF w SUANCE OR
permit is,ss at the ab d state laws relating T EXPIRES gMi'T IS ECTION
APPLICANT Card state that I OF pE
plication ordinances and to enter PERM Y S LLED IN Sp
read this app and county of this cid' gIN 180 D A T C A
that I have 11 city resentatives We)agree to save wIT OM LAS
1 certify' 1 with a authorize rep
I agree to comp Mand hereby oses. ( udgrnents, ,,,FROM
correct. g o erty for inspection purpliabilities,
g0 D Date: �r"
building constructio red PrP f Cupertino against liabilitu nce of the 1 1
to bu merino r-,---
u on the above less the city ag City in conseq
Ind will comp Y
P keep ham' aia st said ids 1 Code,Section
indemnify and which may acc licant understands a" .
in eXpenses the app ertino Municipal Issued by'
costs,and it. Additiona11Y Per the P
granting of d"s peter re Mations
Dint source g PFS; roof is
with all non"P Date-------- gE_g0 installed.If a
9.19. roofing material being a all new materials f
inspected prior to any I agree to
remove
insp inspection,
S; pure gATION
ECLA w for one of All roofs shall Date:
Law
lied without first obtaining�'
•� OWNER-BUILDER D tractor's License L insta
the Con enation, inspeCtion•
exempt front licant: ER
affirm that I am their sole compensation, nature of APP LASSBETT
I hereby m employees with wages as for sale(Sec• Sig INGS TO 'CLASS
two coperty,or y or offered
the following th p is not intended ALL gOOF COVER
I,as owner o the structure contractors to gE
work,and with licensed DISCLpSU
will do the Code) contracting Code)• ARDOUS MATERIALS ter 6.95 of
Business&Professions exclusively oder Chap
erty,an' gL professions gAZ ents u 4 I N''i
f the PrOP 'am Business three uirem 25533,and 2553 the H,
I,as ownethe project(Sec• following materials re4 12 and
of the hazardous
Sectio al Code'Chapter 9. materi
CO er�ury one I have read the a ty Code Snicip
oder penalty of p �lorker's ealth&Cupertino or handle hazardous dous a
insure for California H ith the I store it hazardous
,,hereby affirm a onsent to the Labor Code,for the should whichManagement Dist
Certificate of C compliance N'Section 25532(a) Ment or devices uality
declarations: malt
a r by Section 3'100 O Code, I use equip Air Q Chapter 9.17
I have and will mit is issued should a Area Code
rovided for urance,as provided for this
Safety der by the Cupertino Municipal
ompensation,as P work for which this petation Ins Work for which this Additionally' 25534•
C e of the wo s Compen of the wo contaminants asaliance with the 25505,25533,and
Perform s Worker performance comp Sections
will maintain for the P I shall maintain �qde,
Code, ealt SA .
1 have and 00 of the Labor it is issued,
for which this perm orkeC's ed ag °. Date:
Section s ance of the wor ,Vz-
k e subject to the W
permit is issued. to become exemption,I er
that in the perform manner so as I must N LENDING AGENCY
certifi' n in arty making this certificheeLa or Code, erfor
I any person If,after of the CONSTgUCTIO for the P
not emPIOY of California. provisions deem revoked. a ency
compensation laws er's Compensation unit shall be ed ctiori lending g
est to the W ork or this p a const 3091,C'v C.)
become sub] with such provisions affirm that there is Sec.
N 1 hereby this perYnit is issued
forthwith comply w' CERTIFICATIO information is for which
LICANT above laws relating
lsNam
Affapplica"O"
that the d state bender
d state ces an to enter
tana county ordinan of this city ddress gATION
have read with all city resentativesWe)agree to save Lender's A ,S DECLA
I certify that I ha comply oses.( ments, ARCHITECT
ree to authorize rep
correct•I agconstruction,and hereby for inspection P against liabilities,ju og the ublic records.
to building 'Property
o f Cupertino ag uence used as P
1e above mentioned pr P City City in conseq will comply
keep harmless the against said as and nderstand my plans shall be
t understan Section I u
and k P accrue ag lican a1 Code,
,iify which may the app Cu ertino Municip
and eXpenses it.Additionally,
�,OASc .a of this perfri ere Mations per the P Licensed professions
granting int sours l��\
with all n" Dat
9.18.
Sign