00110126 (2) CITV OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDINGAT)4t$3 POPPY WY DON WADE ELECTRIC COPERMIINO00110126
OWNER'S N APPI.ICA'1'ION SUB 04 li
F�I 16320 HARWOOD RD 1. 1 _g.
16 PHONE: - SANITARY NO. COMROL NO.
(408) 377-2323
M-% ARCIRI FCI'/ENGINEER: BUILDING PERMIT INFO
00 BLIG lil.l!Cr PLUMB MECH
ce
CI I_D
S?j LICENSED CONI RACrOR'S DECLARATION
1 he ch flint mtn I ant Banal tllalar ,Chia t , .n' Job Description
p u,_aQ y a puwsions o pde` ([emmm�m g
Fnty such secantsele.4 oiviamn3nf me Bn,mrs,sad Prmeaanns cede.alt)n+r been,, PANEL UPGRADE AND OUTLETS
i,m fall rune an Jr�l
��(J� d3 O�MT
�-�•
w 3 u Ii, ARCHI'I EC'F'S DECLARATION
F C-1 1 aader,h nd my plans shall be used as public mco d,
,.r
� o o Llunsed Prols"ionw
u o, ceOWNER-BUILDER DEC1,ARXI ION
a 1 nanny aflirm
Ih n 1 am csclnpt fnnn the Comnmmrs Licer,o Law Iia the .
t L< 4dloving muxm31.5.Busi
.(Section 70ness aruf Prolc,inn,Cole Any city or county
F
which pern,I,, ra-towl,afterr desuolikh,or m,i, y.memre
3pccnor I I. y Ule..,liclotl hPcnna,I fl ,acd,lue cal
hat he is serwalp - II he powi... Ille Cvwra,lor,1 (ClOal,9 Sq. Ft. FloorArca Valuatio l
(nmthencmg with Section)BW).1 Dividers 3 of the Botms add Is - :Cade)
or that he is eccmpl therefrom and the ba,i,for the alleged exemption.Any vialefon
of Salon 7031,5 by any apprcalll for a permit subjecb the applicant to a evil penally -
of nn'mare Jnln five Imadred mfaw($51X6.. APN Number Occupancy Type
36615023. 00
❑I,a,other fir the and
the y,or my entplo t intended
dor offered!f sale le(Sec.
7fW.
will Jo the work and I, ode I e is not,le',Li:6 U. for sale(Sec.)I,an RR LEE
1�ypg
"1.Icer t4 pro taty11 ho�endo. ine rovesetnrs Band Law erns ant orgy m an 304 — ROU6H CLEC r tte�'ML
"Icer Ili%oy Wonmilds firimprovesat such
andwhoencs suchworknded or (j
o through his awe employees.t building
that such impnnetnetns aro all intenn.n or
nnamdmn,the.u.however
erwi naavether mtpmvermmnsold undid not yearor 501 — FINAL ELECTRICAL ENERGY
np"we nl me nwnerintylaer wuntave me nmden fir nntvins that undid not buildor 505 —, FINAL ELECTRICAL
,tt Pr I n. :,
01,as ownerIF the propertclusivcly contowling with licensed ctract r,to
fi t thep Jct 6 7ULI Business J Y fe i n:Cod 1 o Contractor's
/�
1n"c I 1 a nl ply' of p pony 1 hu r 'h,rob
and who enmmctn lilt Itch pntJcun with a au nraanrls3 Ia'c '
cnssd pursuant it,the /
GommemrF piunde law.
[Im mp '
1 aexet under Sec. .B 8 I'C for thin rtes+ O
Owner Dam
WORKER'S COMPENSATION DIiCLARATION
1 M1ercby affirm under Innalty of perjury one of the following Jeclam'ions: '
O I have and will nwlnmin n Cenlfeate of C'nwcu In sclf-ovam for WmRer's
Contpcnaaion, m provided lin by Section 37M of the "hot Code, lin 'he
perfonname of the wnrA for x4ich'M1is pemtit is iszueJ.
Cl I have aI I will nminlaio Wnrkur'v Contpen.mion Insurance,a,m umd by Sce't I
9)(X1 of the Febor Gale,for the periorriance of the work for which this pmn t is
issued.My t ker',C, ,,I Insurance lamer and l'll iwcy)number arc:
f•/�/�� Cuficc_��r,lfl'IIILA )P EXIlMI'flllNh OM W 11{��(I'S'
I COAII'EN5ATION ION
F OM
i j X IS p
mo,semimt need not be hmtpleled if IM1eCperntdi i;1an��tI J r Ily{y
IS 100)fir leas) O till T`
1 certify that in the pedionnance of the work for which this permit is issued.1 -
,hall nut employ any ,,.n in any manor,-as'o M[ome object m me W sees'
Comp[nn:ninn Laws of Culifontia.Date
Aprliranl
NOTICE TO APPLICA N'E If,after making Ihls Cceilicalc of Ercmp'inn,you should
hectarm,unjen m the Wnrkcr's Compcnvation provision,of the LtMn Col you nmst
O fntlbwilh comply with such provisions or fill,pernlo shall be derood revoked.
F Zl CON,that,I[ON LENDING AGENCY
I hereby aBlmt w
dmI then is a comcti"n lending agency for the perfomtance
W of the work for which this is nnit is issued(See.3097,Civ.C.)
Lende's Name
Z lender's Addess
U C 1 ccnify that I have mad this application and,fate that the above information is
{a. F. n rrcet.I"gree to cut ly with all city and county urdiwncc,and s,am Iuw,elating
Q U ,haildingaasuvNoo,and hmuhy"mhurim o,m"tuufncs or l hip clly m Gott•.uryat
>, the ahnve-n actioned pntpcny fur innpectlou ptop mel.
F. S (We)agree to save.indemnify and keep hamle..s the City of Cupertino against
W) liabilities,judgments,costs awl expenses which may in any way accrue against said
U Chy in conwsryencu ul the gmnling of'hir Iermil. �//� G (/ m
APPLICA ECUI IER(�1 oS AND LCOMPLV WITH AL1,NON-POINT Issued by: D
� �/ ille ` O
signaln,e..i Arpli[amJci tm[Iu, Dam Re-roofs
IIA%A I., I, M.V'-1,apa stomor an Ii
\Vl bythe Chrantnr wuni ipalCo te,Chatseam,handle ltaaaranand%afcIy Type of Roof
as dc5nel by Cupertino Municipal GNc.Chapter 9.12,and the I lcnhh and Sarety
cWe.wmz551Ia1' El No
All roofs shall be inspected prior to any roofing material being installed.
Will the ahpurworfailure nudding occupant ave cquipmnsordevices which If a roof is installed without first obtaining an inspection, I agree to remove
emit council air contaminants as defined by the Bay Area Air Quality Isanagctnent
. Di.htim9 all new materials for inspection. Applicant understands and will comply with
01'cs FJ No all non-point source regulations.
1 have read the haaaNvuv tnamrials myuirellcnu under Chapter 495 of the
California Health k Sony Gide.Sections 25505.25533 and 25534.1 understand'hat
if me N.Idi ng docs no'curenlly have t ore 1,that I is my rc,pnn,indqu,notify the
uupnnl of the m,u4,rwnla which mutt he mel prior m I u,nlo of a Cenifalle of
co Signature of Applicant Date
uwnelaaalnnriar,Iag<IOmo� All roof coverings to be Class •`B"or better
OFFICE