080602526Wi C
❑C
UOC_
LL
U2
CITY OF CUPERTINO
'aw•,'ks.si` C �t�'-'���i " �/� °��
BUILDING DIVISION PERMIT
CIO TORfX10R�L!✓N
)a Y
BURRING ADDRESS:
PERMIT NO.
1
.1601 STEVENS
TBD – TO BE DETERMINED
ngnCO292'
'S NAME:
PERMIT ISSUE DATE
0 8
PHO
A CONTROL NO.
ARCHITECIIENGINEER'.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MWFI
LICENSED CONTRAC DR5 DECLARATION
lob Description
1 hereby of irm that 1 am limnsed under provisions of Chapler 9 (commencing
p
with Sectio 7(RO) of Dodson 3.f the Bonn. end Profussions Code, and my It.. is
In full force andettm
CODE COMPLIANCE, INTERIOR WALL @ 2ND FLOOR, GUARD
ote�a. CCaeumar
RAIL, ELECTRICAL OUTLETS–THIS PERMIT NEEDS TO
ARCHITECTS DECLARATION
IundersunJmyplansalWlWuamtuWblicrteords
COMPLY WITH THE 2007 CODES NOT 2001. ORIG PERMIT
Llccused Professional
OWNER -BUILDER DECLARATION
1 Wuby affirm that 1 am exempt from the Contractors License law for the
following mason. (SeNun 7031.5, Best. and Fmfessmos Cade: Any city sir county
which rtyu;m, a permit to ConstrvcL ales. i01 novo. demolish, or repair any svunum
prior to its Won... also us ubus me applicant for tech Permit o file a signed maument
that he is licensed pursuant to tho provishom of th, Conuractor's License, Law (Chapter 9
Sq. Ft. Floor Area
Valuation -
(crmmencing with Section 71)(0) M Division 3 of the Busnea and Prokumona Code) or
S20000
that W is exempt therefrom tib the We$ for the alined caemption. Any violation of
APN Number
- Occupancy Type
p y YP
Section 7031.5 by any appliunl for a permit subjects the applicant to a civil penally of
Oman an, mom mftwhundreddollam(SRIO).
32660001.00
❑ 1. as owner of the PwPmty, or my amPloy. wW wager u their sole compensation,
Required Inspections
will do the wart and the sunpme tint rounded or offered for ask (Sec. 7041. Busimsf
and professions Cade: Tee Contractors License ato se law does m apply an Owner of
property who Wilda orimprows th mon. and who dressuch workhimselfor0uough his
awn employee's, provided thataeh improwmenta art not insentient orortered total. If.
-
bmvevee,theWillingaknprov ttstoldwhhinmyouofmmpltim.meowm-
Wilder w0 haw me burden of pronng dist W did ml build or improv for purpose of
ale.'
as owner of the property. am Lvduswly contracting with licensed contractors; to
usmt the project (Sec. 7044. Boulders and Profcasons Cotler) The Convacmrs U.
cense Law does not apply to an owner of property who Wilds or improwf memun, and,
who contracts for such projects with aconeatelods) licensed pursuant no the Convectors
License taw.
Gare rem de, See w / . B d: P C for chis wastes
m � ORKI �/I 40IN DI L/ Dai
WORKER COMP 5 TION DECLARATION
1 bureby attire under penalty of Perjury orc of the fallowing decoration:
❑ [hawand will maintain • C.nifimuofConsentt. self-inmuctu WorkersCompcn-
scion, an provided for by Section 3700 of me Labor Code, I. the perfannanm of the
work for which this permit is issued.
I hew ard will maintain Workers Compensation IM1LYMm- m required by Section
37W of the IaWr Code, for the performance of me work furwhich this Permit is orted.
'
MY W Ukces Compensation ]Mo. tuner and Policy oumWr are:
Cartier. Policy No,:
CERTIFICATE OF EKEMP ION FROM WORKERS'
COMPENSATION INSURANCE
Crus ]Lemon Used rot W cwpleed If the permit Is (worn hundred drifters (SIM)
or leas.)
I certify, that in the, performance of me work fee which this Permit is issued. I shall not
employanypemon in any manrero obccome abjecltotWWorkeri Compensation'
lswOfof Cali
!
App
NOTICE TO A &NT. If, IfteFrAkingason this of Eampdaa. you should
viNnau
became abject to the Worker's Compensation
thi n provisons of the lahae Coda, you must
or
, faMwim comply With such provisions or Nu permit mall W decreed resoled.
CONSm LENDING AGENCY
hereby is acION
thi Nat thin iss agency for Nc Performance of
the work for which this permit ts iauW (Sec. l(19'f, Civ. CJ
which Issued (Sec.
lenders Name
••^-rf Atldmv
1 cemily that 1 haw read ws application and same "use BWw information is
correct. I agree to comply with all city and county'srJinarurs and state laws relating to
Wilding construction. all hereby aumosae mpmsmtatives of this city to tour upon tae
'Ww-motioned Property fee inspection purposes
(We) agree to saw, indemnify and keep hannlea is, City of Cupertino n1dUM
j Iiabilitim J.notena, coca and expenses which may in any way acerae against said City
ofineganA of Nu permit
A APPLICANT
APPLICANT UNDERSTANDS D WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOUR GULATIONS. )/ /
!/
Re-roofs
Type of Roof
14 ' ? o
Si resit AppliaMCo e Dauf
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or forum Wilding occupant sort or handle haardouf material
fined by the Cupertino Municipal Code, Chapter 9.13, and la Horth and Safely
-
Section nsn53a(')' P6 Nr
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the aPPlicant or future Willing amupanr 16C cyvipment or Jcvixs which
..it haeaNnns air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
Dist/ cR
❑Yes No
M
I hew maty IW hevaed r of IW Caldor.
demoned.95
D5. ]SSA uW2s53d.Uurrmmand thatifdre Wilding
on, 25 .25533rtmc 5534.1
nu Health&SaloyhowaScean
that
darn not curmnlY Mw a enanl los' my responsihiiiry m rrrtifY the aecupant of me
rnit,whichmumlcmetUnmanlauanccoftCertificaeofOcmpaney'
Signature ofApplieant Date
MA4-4 90
All roof coverings to be Class'W' or better
Ow Dae'
armthansd egcm