00110122 CITY cN
uPEHrNo
IL PERMIT CONTRACTOR INFORMATION:
BUILDING AI]D§6'
00 HOMESTEAD RD DEVCON CONSTRUCTION YrllYN0.00110122
OWNIiR'S NAME,.INYICRACKER '5551 LOS COCI-IES Ell' APPLICATIO�[�)B/,I'{12000
IHONE: (408) 942-8200 SANITARY NO., ( CONTBOOL NNO.
q O ARCIII I'BC9]CNGINEHR: - BUILDING PERMIT INFO
kC w C BLIXI ELECT PLUMB MECH
�c'4O^E Ihemn LICENSEato D CONTRACTOR'S DECLARATION
Cmplcr9 heomme,mang Job Description
c'5 z4 yin to
with Section and
of Oivixinn 9 ufdte ltuxinemx and n,l'easlons C�xlc
Q_Cw ', �m"tyre""` T:[ DEMOLITION OF EXISTING PARTITIONS
s Y�� t in full force and efRct. /_
z License Clas: Lic.x (�J -
O et� Data Comnmmr_R(s0
3°•y ARCIi1TEC'1'S DECLARATION
<�< 1 d t plans.hall o used as public issued. '
w 5❑O Liecnw+l Pro cssmmJ
OWNER-BUILDER mDECLARXI o CondoION
uai= 1 hereby alien❑m1 I 1 eEemp.from The GanmisCo License Law for the
G G fnllnwi ng ammo..(Sell t youslo Earliness imp io,ve.demob Codu:AnY city nr c0m.y
Y D
which ns issuance.
also roroms the almsimprove,h Permit. firepair any swcwre
a3�
prior e,he.s I iewaaeauseamuires flue proemlicant oDhe sucCmInsnor,Limasle Leedsmmroem
Imm�ei.xecce.dpSc,rrum70(n) fDivisi nr if the I.el.awlcnamcr9 Sq. Ft. Floor Area V�jlt,grr1pp
(enmmee ingwithgemlunont ad Division oaf to alleged
c.mpilo.An,
Gxo) Ls1sLr¢1 YJ 1�I -
or that he 7 31.5 b t..,m,I and the basis for the alleged ni...on.Any violation
of scclion]OILS by ony upplicam for a pemtil subjects the npplicum m a civil pcnah
than APN1Nful�t�e�$� V.
Occupancy Type
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is 1101 Intended or offered lou sine(Sec.]bla.
Baeince,and Profession,Code:The Commcmr'.x License Law does not apply et an e (t
owner fpmpdny Who builds or improves themes,and who docs such work himself NO ASS IGN9&u%dRTf 19bN5
or through his own employees,provided but such impiscmema are mm Intended 0r
011cred for .It.If,however,the building nr improvement is sold within one year of '
completion,the owner Wilder will have the burden of proving that he did not build or
improve1,,sforwn purpose uLsoleJ,
❑I,as owner of the progeny,mo Business
a contracting refiwish licensed contractors in �//
name the present(Sec.yuan owner of and property
who
G,Jo:)improves
Gmtmnm',
and who
Ire docs not apply ro tat owner of a comy who halide seimproves thereon. /
and Contour Licets for such gausses with a canlmenm(s)licensed pursuant m the
1a.escria,under
Ire.
❑l am esentpl.nAer see. ,E xr r c ate mit mason
Owner nam .
WORKER'S COMPENSATION DECLARATION
I hereby affirm under,malty of Ie jury one of the following decl:mahmils
1 have and will n ainwin a Certilicam it Consent to self invere lin Worker's
Cempemmion, a, goaded rnr by Section 9700 of the Labor Code, fav the
Nd Dance of 1M1c work fur whicM1.hi.x permit is issued
1 I 1 r end will maintain Worker's Cnrnpenxmi0n Insnnmoe,as egnired by Scutlon
011 of the Lor Cale,for the perlmm ace of the work To,which I)us permit is ,
sued,My Worker's Compensation Insurance canner and Policy number nor
Cmmicr: Policy Ne,
CERTI ricATiON OF Er EMPTI ON FROM WORKERS'
COMPENSNOON INSURANCE
(This section need not be completed if the Permit is for one hundred dolloo r
ISI00)orless J
1 certify that in the n liana ma n the work far which this permit a issued,1 - -
shall not employ any person in any manner so as m become suhjem m the Workers'
Comitant .Lox'.of California.Dem
NO AppuCE
NOTICE.in APPLICANT.Walk IL Cna making this
ovisio s i of Lae...C l you should
becnmch can mthel urker's Compensation mmait lmoRhe Iran„Code,you most
z 0 forthwith enngtly with wch prnvlxiuns ur this permit sllull he dccncd revoked. -
F redo CONSTRUCTION LENDING AGENCY
a ' i hereby erdrnt ohm ihcrc Isn untxmuc!on lending agency for the permmmtee
of the work for which this vernal is issued(Sec.301 Civ.C.) '
0. Q Lenders Name
7 z Lends',Addrox,
U O I certify thin I have mad this appumai.n and stale Out the move information ie .
f; E„ correct.I agree In comply wish all city and county ordinances and stale laws relining
O t� mi ildingento,ameti.....and bemny nurhurize�.prcnatulllve.v nl l lis cay ,,emernpun
ry the above-mentioned property for Inspection pstai s.
rOe (We)ag.m,wee,indemnity and keep harmless be Cilyor Cupertinoagain.,.
rp liahilitlo,judgments,cost.and expenxen which may Ira any way neenre against said
V z City in emacyuence nr the g,ataim,of this permit. '
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
r SOURCE REGULATIONS. Issued by: ��C Date
Signature of A,Aicmu/Cmnmw w Date Re-roofs "
HAZARDOUS MAT17RIALS DISCLOSURE
Willdte appinanm Baan,building ov,,o me rate or haaotln hazunj^eIa"matennl Type of Roof
as defined In,the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cede.Section 25532(x)? ��,,,,((
°Yes _ osis" _ All roofs shall be inspected prior to any rooting material being installed,
Will the applicant or future Wilding occupant use overprice,or devices which If a roof is installed without first obtaining an inspection, I agree to remove
miI hamrdnu,.1 rt.tamitunta a,defined by the Bay Area Air Quality Management
remiet, all new materials for inspection. Applicant understands and will comply with
❑Yee No _ all non-point source regulations. ,
I have real th rradius I Ime,iA,myuiranenrs undo,.Chapter 5.95 ol'tha -
Caliform Hcalthk a y Code,S pions 25505,351?and 255341 understand that
Bit Ing re i uvemly even,...t.the.it ism,res,moibilifym notify.he
.,an,of yu acnes Ich ma.a be nt,pdr,ro ivxaunce life Crenf,atc of
Oc atpan �''n' Signature of Applicant Date
ownermma n ,argent �ruam All roof coverings to be Class"B" or better
OFFICE