00050210 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS PERMIT NO.
21 ,427 METEOR DR1
OWNER'S loll API'LICA'1'pp)N' '012050210
PHONE: SANITARY NO. 05/9INykNWO
C 0 ARCHITECUENGINEER: BUILDING PERMIT INFO
BI.DG ELECT PLUMB MECH
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SNC thin
CON IRACIOR'S DHCLARAUON
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O z_ 1 hereby ought. ut I Din Ilmnnscd under poe,ninn., d Chapter 9 mr,nuneneing Job Description
mI- wllh Section 700%Iter Divi.inn3of,M1t Businea,and l'mfessumcadc.and mylinnm
ti- is in full fore's' I It
z y 1;.re Cy
Doc S 1,�s Q� Cotnraclm�
a I, ARCHITECT'S DI[CLARA'nUN
1 rude caand my Alun,shall h used as public record.se
v
Z Oi pC Licensed l'n,fc<sionnl
40 OWNER-BUILDER be CentaUN ELECT SERVICE UPGRADE_ V
I hereby.(Siem that 1 am.Baia frond,he Commc'ra License y.1 for the
C z following reason.(Scnion 90313. A cr,and ,ore fans Cada:Any city or ad'ny
z=o whiM1 P 'miI cher ' p I t1 p' Y.t ecce
prior to itsala)n4 [lie applicantfor such pe t fl g ed:,a neat
>s that he is licensed prsa t to the pauvesicars,ofth c t t r' Licare Lo (Chapter 9 Sq. Ft. Floor Area Valuation
(connncnnng will,Seceon 700mof DFino 3ulthe Rav a and Professom Codc)
or that he is exempt ihertran and the basis dirt the alleged exemption.Any violation
also 1131.5 by any upplicam far a petndt subjects the applicant ,a civil penalty
of ran,tome roan live hundred dollum($500). nAPN Number Occupancy Type
O I,as owner of the property.or my cmployem with wages as their wlc eompenwtinn,
will du the wor4,and the structure is not intended or uttered fur sale(Sec.904i,
Baits,amt Prnfa,.inns Cold Ilie Crncralue"I,icenw Law docs nal npnly In an Required Inspections
r of prapeny Who,build,on imptnvm theorem. ad whit dws such work himself
unhrough his own employees.provided that such improvements are Dol i(omnded nr
cla red for sale.It,I..."I r.,hc building a impravument Is.air within one year ul'
completion,the owner-huiWer x'ill have the burden of proving Thal he did nm build in
improveI purry),c of sided. ,
❑I.as notary of the pmpt am exclusively canamming with licensed comarrois no 304 — ROUGH ELECTRICAL
eastmci the project(Sec 90'rS,Busirl and Prole ions Cade9'Bw Cnntmctor•.. 501. — FINAL ELECTRICAL ENERGY
License Law dac,nal apply n,an owner at propcny who builds to,imprrww mown,
and whn contract,fin such peojeets win a cwlrill licensed puran" In the 505 — FINAL ELECTRICAL
Cnntmeto",License Law.
❑I it,axmmp, for See .B&P C fur This reason
Owner Date
WORKEWS COMPENSATION DECLARATION
I hereby uftinn under penally of perjury one of the following declarations
40
❑ I have and will ma'lmn a Ccnifcam of Camcn,in self-insure for Wnrkcr'x
Compensation, as pmvideal for by Section 30(X( of IM1e L.Mrt Code. for IM1e
performance af,ht work Tor which his permit is issued.
❑1 have and will maintain Wader's Cnngmn.mion Imumncc.to,reyulred by Sectlaa
3701 of the Labor C,de,for the penurmance of the work for which this permil is
,sued.My Wmdar'a ConOmnxalion Imuran.:carrier'and Policy annever.are:
Cneitr. Policy No.:
CLIO FICA'1'ION OI'EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sectian need not be conflicted if the permit is for one hundred dollars
(SIIU)ar lost
I cmify,(wt in the perfnnnrare of,he work fort which this permit i,issued.I
shall nm employ any ,an in;troy manse on to,
to q IN-I Io,hc Worked
Cumpens.tilyws f�CalifyR��.Ume Oss�aj)O✓
Applicant ll- p al.✓ /-
N(YTICI?'I'U AI'I'LICAA'I':IL:dmr maklr this Ccrtiliaru nl Brccndp,ian.you shoulA
blematwbjee m the Worker's Competentpravisi'n of the Lahan Cade.you must
Q 0 forthwith comply w'nh such provisions nr,Thisµ.tit shall he deemN revoked.
f = CONSTRUCTION LENDING AGI:NCY
LtiI hereby alfimd that them is a conamctio r lending agency for the performance
of the work far which this permit Ix issued(Se.109A Civ.C.)
L Q lo(oder's Name
Q Z loader's Address
V O 1 lellyflat l have read I...a,hcnlinn and state that the ntxn'e iNirtn'tien is
Ices L. correct.I agree to comply with all city and county(ordinances and stale lass reining
[) m building ,instruction,and hereby carmine representative of this city.enter aft
,he ahnvennemis tat Prupeny for mNRYdon purPmsc,
rrF. y (We)agmem,so ,indemnity and keephamdc,s IM1e Closet Cupertino agmina
4 liabilities,jud,nmm,,cost.and eoµn,es which may in any way necme against said
V Z city''tometNenec of the 8run,ing of,hie ltttrnil,
APPLICANTU'DERST!!l���NUS AND WI LCOMPLY WITHALI.NON PoINT Issued C Date
SUU EREGI .ATIONaI 3-�'(r �) grin y'
"produce of A"'m ,mens—� �J Il.ne�— Re-roofs
HALARDOUS MATIiIIALs DISCL(ISURE
Will the applicmt ry future bnddndg ac,:rlam,lare or nandle ha:ardmr.material Type of Roof
us defined hY dhn Cupertino Municipal Cdde,Chaprtr OJ2,and the Health and SolBIy
Cade,Section 25532(al'! N
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future haBsngoccupant use equipment orties ices which If a roof is installed without first obtaining an inspection, 1 agree to remove
emit hazardous air conuani moms;is defined by the Bay Area Air Quality Management
Disarm? `f all new materials for inspection. Applicant understands and will comply with
0Ym 1"a all non-point source regulations.
I have real,bc hemNnu,mncreds rcgnim cros under Chapter 645 of the
California Hcdh&Safay Cade,Section,25505,25533 and 25531.1 undemmad aha,
it the building ants nal currently have a tenant,that is is my mspmvhilily m notify the
p' of m
dee reyWreemm
,wIn I nN.I I InCI pant lin r.eatc or a cernecau of
"`'San x"`y' . Signature of Applicant Date
f-� —`�"aA-Q. '�- S 3ned� All roof coverings to be Class a`6" or better
sed
OFFICE