00080132 CITY OF CUPERTINO
ImILDwc DIVISION PERMIT ' . CONTRACTOR INFORMATION.
BUILDING ADDRESS: _ -c11
PERMIT NO: ,
OWNEWSNAM : I -, APPLICATION SUIT DATEMA 17
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ullmul
7NE: - - - — rl - e t SANITARY NO' CONTROL NO.
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IITLCT/ENGINEER' - - , BUILDING PF;RMI'F INFO
- •;t, �BLDC, v ELECT i'IAMIi MECH
.rS ) IJ"- ICENSLD CONTRACIOR S DECLARATION1I n .« ,II Ir d d n Job DescriptionoY p : fCl er,9( n cngSeeuon9000)olD 3aftneeu AP nlesso Cor Idcry 11 IClase drffcl - .5; f
Irxi 31st.,'",, : Date Conformer _ .,` e - 'A/C,,UNIT. •y' . J ,,, ._, .
O ` ARCHITPCI'S DECLARATION
��m� land¢ 'I a ypl ..h 1lbllsela phl' recrrds -
ac, .LiceaselP desfoal
n ce a. ' OWNER BUILDER DECLARATION
w=m 1 hradY alTrm Inn t a n corrupt from theC I I r, LICE L forth a
lollowm,anion (Section"1031 5 Bus hes. d l I : Code Any rut,or n ntya
al F D which - permit m comtmet alter,improve,- de rI sh,m roper any ap cwra'
Pan l I '1' requires m I pF I hasn't Permit I I g antemenl -
, 55 mala dal I m p , nI c I I Lu '(Ch pler9 S Ft.•Floor Area - f -
(co le s 'IIs t 90001 FD l nn B ' IP r: CcNe), Sq.-Ft.-Floor
�. Valuation + ,;
orII t h PIT f d Theha 'f II II g U pr A)violation
ofs F ead 7031.5 by yredd tr p 'tmbJvcls lht;app]' and mae'v'I pcnanY OCWpaI1CY..yI)e
'non I ore man rve hurtI red arllarr,(5500) 1 APN Number '
5
.pl. rIl P
Perry,.racy pl Y 'Ih p mm3 n -
11 d In k d thewr I I I d d b rf e l f s'I (S 9044 r
Bar d 1-f.:c 'Code Th Contractor:L' L 1 r pity I `/.- r' ee4mired'Inspections'
oxn 1 p p rty Whob Id. ......Ih d 1 does h k hI If , - -
rm bnhis; ply ..p adEal n b I earl ad - 303 — ROUGH MECHANICAL_
offeredf 1 If. theb 'av g ilp In IA he
emit of - � '
completion,the h Id rx"1l hese lheburden ot proving he dd col bit"Id or -
mmvenapnrprserfrale.h `304' —. ROUGH ELECTRICAL
ul 'ID I,aD Ownerollne Pip s> I Ir I l g ch I d t Irsm ' f 5$5''-'.'FINAL. ELECTRICAL -
amt Int mopet ne,no(Side"11144 B s dP f..otol d. a Contractor's • 506 _ FINAL_ MECHANICAL
construct
ee : L t v not applysuc t cif property er(bmld. p x Weroon
and who Livens for, JECIa with 'I linlm(s)I I d p rn am to Ice
' �Gmlruclors License Law. ;
t ❑I"vm axe npl under Sw. Ii&PC in, recon
Owner Date FI .. :;��
-. -WORKER'S COMPENSATION IIF,CLARAFION
1 hcmby affirm under penalty at ,,jury one of the following bc]ii.ord,: ' -
' Y
1 h A 'II Luc w C ife�l LCmsen to s If"n.' - f Worker -
omp : Ion ds,pms'ded for by Section 9700 f Ice 1 h1 r Code, for IM1c ' r
perfornanee of the work for when this pen issued.
D l)of the ab w na t or[lie citta r ate f Insurance. 4 d by S conn �; -
issue of the Lake,Cale for me.hismmase of the work firsI h this pmm"t is _ -
ismcd,My Workers Crmpensatinn Insumnee cortico and Policy numher ore:
.. {,
Cartier: Policy No.: - r
CERTIFICA'T'ION OF EXEMP NON FROM WORKERS' '
COMPENSATION INSURANCE '
(Th c need nut he can leted Idhundredt I•
p permit ix fico JnlWrs '"•
I call}Ihnl rn the pedormonce o_f tl " 'k f r wth h il <N I is s edN
'shall I ply any pe y a, Ir become. bjvu In the Workers'
Comprise on Law.of Californ',i,Dac
NOTICE,TO APPLICANT If f1 making II C I f f L nip( >m should r
O Zbecome vahwet to Ind W ke C p I p I II Labor Code yo I n1 i
Eumvith nnnpl)wvh s I pn Ih p nn shall he A I kcyl. .
r
a - CONSTRUCTION LENDING AGENCY
1 herby m ml Ih I There lend ng aged,far the pelf nanve r
of the work forwhen thispe ml is Issued(Sce3007.C'v�Cl '
W A Lender,Name
V z Lend Address -
- I cert fy Thai I have od In'. ppl'-3( a d:I I th I theb f ( n s i
Fti [r enrrecl 1 ag xe m comply Aim all c Iy add mnty radial d.dre laws relarm,
O V aloidlagcnnrectian,and hembyrom...ize rep2reolpliveD of lM1ir city In enter upon - -
"W me an nl d p Peny 1 s0 t' Purposes
- - I
P. I'ahill(W)al, nree ,, I metrically fy dk ph 1. IheCty fCp i e s1 . ..
r.pen,c,which Dy in any way c v abainrl d r ,
6,1 City corse,once of thega ung of this perm ,
APPLICANT UNDERSTANDSANDWILL COMPLY WITH ALL NON.POINT Dtle
SOURCE REGULATIONS Issued b 1. •-
. 'Slgnelure or Appllcam/Contmclor Dice Re-COO s
HAZARDOUS MATERIALS DISCLOSURE
Will me appOrnm or ft mm he umg derapetl social h,I n n- d (dual 'Type.of Roof -
vs def ted b the Cupertino Manic,eaI Code Chapter 9.12.I td the health end Safe,
Code S c 25532(.)". . .( -
❑res ❑N All roofs shall he inspected'prior to any roofing material being installed.
I m ppl ' i Ire buildrit,red q ay a i mI a, m 'Elan If a root i5 installed without first obtaining an inspection,14 agree,to remove
rout kicl? 1 cr nam ca ns as Aefned by the'Bay Arta AirQ ItyM ngumenl - s
oYe ❑Nr all new material0cor inspection. Applicant understands and.will-coihiply with
all'non-point'so'urce_regulations.
Iroad IdThe hin J ,u '.Ir mduneni tinder,ClisTann.6.95 riche
Califo aH slfI &SaI'CIyCdSli,n,2550.925533imd25534,lundstaiidtliat
ifthe tarld gd corm currentlyha a tenant,Par it 1:my bodullr ladirythe
decorm of the requrennls whichnnobe, tp rtoissuance of Cenfcace of
oeeapaney. o Signature of Applicant Date `
own¢ mrrrxdspen < Dale All-roof coverings to be Class "B"or better' -
.;i. - , r OFFICE '