00060035 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
IfU ILDING ADDBPSS: PERNIn'NO.
OWNER
'ti^ I89 WHITE-FIRR l,1APPLICAI'I ti ) , ^
TONT: .• %ANITAR
n z ARCllHEC'I'/ENCINEHR: BUILDING PERMIT INFO
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BLDG IJ,ECI' 1'IAMB N1IiCfl
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� LICICNseoCDNTRACfoR'snreLARnnoN - J bDescription
— hmxhv ulRrm that I am licenced coder p....i.int+s oI Ch,"',9(c trucncing
0 p with Senior 7i%M)µ,fDivi,ion Jnf the Business and l'mfecainns Cntle.and myliceme
a m^� is
in lull force and effect.
3a< [;,(c au, Lie.« FURNACE
�, Uum C,nnr.,cmr
Faa.'' ARCHITECT'S DECLARATION
$ ,�,j I understand my pions shall M tsar a,puhlic ncrad.
se Lib�p O Llrensrd I'rufcnsimlu
C neOWNER-HUILDIik I)ECLARAI]ON
al.g v 1 hereby of imt that I am esempl frznn the Contractor',License"v,fill the
F Z�' follow'ing mason.(Section 7031.5.Business and I'mfes,ions Code:Any city or county
s z D which require a punch tuO.alter,improve,demolish,or rrnair any stmcwrn
eke prinnoils l"earca,uboe...ins lhea"lleanl l'onuch penniuo We a rigned lracutcal
dam mal he isneer.edptowanlmmepro,imma.mthe Cooluam..rueen,el.twlCnapre.v Sy. Ft. Floor Area valuation
(commencing with Section 70%p of Division 3 of the Business and Pmfessinn,Code)
.,,,bar he is exenryt therefrom and the oasis for me alleged emon,llnn.Any violation
ur Se,64n 71131S by any upplicarl Tor a permil,ubjce,the a,plicma Ina civil panaltY
of nminnrethan livehandmilcol la,,(5500). APN Number OCCU ' pe .
01,as lux mer of the properly.or my employees with wages as their sole a+mponmtion.
will Jo the work, lad the anabae ie all intended or offered for sale(Sec.7144, -
Ruane.,rmI Pmr.vdab,Club:'IIll,CnIall...nr',L jccn,e Law dna.ma apply loan `. equiTed Inspections
nr of property Who builds of improves thereon.and who dms such work himsell
through his own ctnployce,,provided that such improvements am not included]or
altered for,ale.If.however,the building or bnprosvneat is,old within one Year of 301 — ROUGH PLUMB I NG
n..plec f„r me owner.,ailed,,will have the burden of proving that he did not build or —
nnprov� pcpneo 303 ROUGH MECHANICAL
❑I.a,owner of the Po,latae.aclusivdy cortowfr,with licenved oneracers to 304 — ROUGH ELECTRICAL
car the project(See 7044 Braine,,,and Pmfc,„inns CWT:) Tic Cono-u.mrs
License Law ace,int torte to an owner nr pmpeny cbo..lice or i,nprnves(tolbo,ar, 505 — FINAL_ ELECTRICAL_
arta rant onntmer,t1,r porn ami«ts wain a romrunnlsl licensed punuam m the 507 — FINAL PLUMBING
Cnnlrenur'n Liccnx law.
G l an,c,entpt.rd,r See. .B,@ P c 6n cis reason 508 —b FINAL MECHANICAL_
owner Doc
WORKER'S CONIPENSAI'ION DECLARATION
I hurehy nl'llrtn coder penult?of Peale,?one of the EJlowing Jcdarpimu:
C I hoea and will mvi&n a by Section
of Consent 1n,elaborre for Worker.
Com peaarv:eo. he provided for by Section nal of me I.IMrt CNc, rid the
purlormurce nr me work for which Ilii,permit is Lv,ucd.
01 have and will moi aloin Worker's Compensation Insurance,as required by Section
3700 of the Labor Crates for the performance of the work for which this permit is
ir.wed. EN�orkgr'.a Cnty motion 1pwrance curtier unit Policy naust/nbe�r are:
Currier, YIf r-i l twiny Nn.: _�Gm3_ _3_)o1_
CERT INCAIION OF EXEN119'ION FROM WORKERS'
COMPENSATION INSURANCE
I,Iii,ucl n.cd not be a urp elyd li Ilea parmi,is rnr one Icndral dulat,
(5100)or Icas.)
I certify that in the perWmlance u1 the work hir which this permit is issued.1
amll uol....ploy any person in I neunner so a,Io cloone xobject le Lha Worker,' .
Compcnsatien Lows of California,Dale
Applicant
NOTICH 10 APPLICANT:If,ager mrkjng this Certificate of limlapf.a.you should
healue wb,iect to the Workers Conbpensutlo..previsions of the Labor Calc,yuu all
O Q fmthwilh eomply rill,such pmvW,a,or Ihi,permit nhnll he deemed myoUri.
CONSTRUCTION[.E NDING AGENCY
aI hereby nftinn that them is it c nbuction lending agency for the perionnano,
W of the work for wbiuh thl,pencil is Lamd(Sec.3007,Civ.C.) ,
:L.
Q lender's Name
D z Lcnder',Addra„
V O (cert lfy tba Ilo,a re,ol his applicalion and,lac thin lhoabove lrkantruou is '
gt. f uano,O.I.gree o+cneuply with all city and ca in,y ordinance,a I aaac law,relating
O V to budding construction.and hereby aamnn.a reprewnoliles of this city to enter upon
y ;4 the adrvs.nberrnlued pnumny fat i+npeelion pur,ows.
p„ (We)agree to save,indemnify and keep harmless the City of Cupertino against
Ur) liub,lit i.a judgnbetn,,'ea..nJ.,pun ,which may e..any way accrue IeLilua,rid
f„) Z Ci1Y in ansequence tt��f me granting n Is permit.
APPLIGNT UNDERlI. SANT ILLCOMPLY WITHALLNON-POINT' Issued by: Date
�
SOURCE REGULATIONS. ./ =0�
Slgnomry nfnpplicun 'onvnctnr D Data Re-roofs '
IIA.kRDOUS N1AfERIALS DISCLOSURE -
Willtheupplicaraorfummtvildirgtacupamemo,handichusebotsmaerial Type ofR
as dotittal by the dpertino Municipal Code,Chapter 0.12,tour the Health sad Safety
Ode,See, 25532(a)P 0N
All roofs shall be inspected prior to any rooting material being installed.
Will he tmpR<amid foolm nmldllug te.nparl rte c,ptnenl or device,w bieh If a roof is installed without first obtaining an inspection, I agree to remove
aunt".'ado.,alt.I .roan.”- r,deford by the Ray Area Air Quality Nlarigemenl
District? all new materials for inspection. Applicant Understands and will comply with
GYc, 0N all non-point source regulations.
I nave read the huanlwu materials equi ranerls under Chapter n 95 nr the -
Culiforra Health Pe Safny C, J, Scc'unx 25505.25513 and 25534.1 under,tund that
iflhe building fres nut curtently ha alonanl.that it ismym%,arrihilily u+notify the
.rep o,'If IN,requibemenu whi mea he met prior In issuance of a Certificate of
rxcupun<y.
-00 Signature of Applicant Dale
ownerma nriaedagenl Dale All roof coverings to be Class "B" or better /y