Loading...
HomeMy WebLinkAbout00020063CITY. OF CUPERTINO .. PERMITNO. ,BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: p OZ Ofl�3 BUILDING ADDRESS: 'w ' •(� SANITARY NO APPL CCAOT NTR OSULBp MITTAL OWLS/ E / Ar1 T r` N/C •YNV61.: � S3 om . ARCHITECT /ENGINEER HULDING PERMD INFO X00 S. YNC/iP/de JAS C i' b m '=2 - LICENSED CONTRACTOR S DECLARATION r • r. O°z p I hereby affirm the I .m licensed under provrsons of Cheput 9 (commeoetng �� , J '`-�( '. • Job Description F t-u. withSmtion7M)ofDLViSiOn3ofs Busimssmd&fwrom Cade,ardmYlicemeis i Eyi in fullforceand eRttt y� �f �� QUd67u li .,, .Clan _ 4a.x /�')�y , /.. /f �/VI;�5 . 3 a y Data Conwcmr VV 1 ('f �=.1� t u O Q ARCHTIECS DECLARATION I understand my ph W ns anal) used as public records HMO �(c Licensed Professional OWNER- BUR.DER DECLARATION ' 1 MabY.aRum mat l Am exempt from she Contractors Licanse Law for the • • - r - _f O (thawing reaar. (Satim ]031.5, Bmiass a:d Pmeaima Cade: Any city «manly •' — m wldch res lima A Permit to construct, stoat, improve, demolish, or repair Any structure - . 3 S .-Ft. Floor - Valuation prim to its itmona. Alan requires the Applicant for.uch pemit to me A signed statement' mat he is licenasd pursuant ro me provisions of me Conencon's Limner Law(Chaga 9 (c.n.mgwilnSmil n] ogo). fDismion3ofheBuel aaadProfeaiomCOde)ar APN Number Occ line 'ryI Wt he is emmp, therefrom AM IN, m basis roe e alleged ...,Ban. My violation of / /L © O ' y • J p e - ' Section ]031.5 by any applicam fore peat, subje ni me Applic. to a civil iumhy of nm mom man five hundred dolls 0). 1550 [] 1, as owner ofN<propcnr• or my amployas wit wages a a meir epic compensation. Required Inspections w91 do the work, and dte.wmurc is or intended or offered im age(S.. 7B00, Business 1 Add Profe amen Coda: The Cmuaclole Liame law does the apply to An owner a ' piopeny who builds or improves mermn, and who does such work himsalf or through M1is own a yeas, provided the .uch improvements are not intended or offered for We. if even me building or improvemem is Bold within oneyw of completian,tha uv /r!A bas vac .asv n dtt will have rise buNen of proving But he did not Wild or improve for For., OCT q q e „ err etl <.). C O' 1 L002 Les owns of me property, . Business AM contracting Coe licensed useur. to a , sera the pmjeeo ISa. ]010, Bmmcu aM Professions Code) Ttie Comm�or'c u ' cenm w dos tot App r of property who Wilds, in impmvm meson, end - - - .1mom Sts for jots wish. matrachm )limmedmirm! it N Contractors Lieaw law. .• BU WING ' ❑I....e sun ,B &P for - - Owner DeO7 ORKF.R'S COMPENSATION DF.CLARATIO - •• 1 hereby affirm miler penalty of perjury, We of the follaviog dahntiom: r I hove and will meimW..C<Hifica1e ofConsm, to a<16imme fm WOrkeb Compem worm, r hick 61 for Section 3]00 of the Labor Code: for the peAomtincdof rise, work for which ill maintain is issued ❑ 1 have and will m e, for WnMcrs Compensation tic for hi as required by Session 3]y W.roes Cm Comeau rthe peiriceI ia, Add for whichmiepair is issued. My Wurkele Compensation Inxurona cersitt end Polley number off: , Carrier. Policy FROM CERTIFICATE OF COMPENSATION I N FROM WORKERS' " COMPENSATION INSUMNCE - ' (Thin secdm mad nor trcompleted ifthe permit is forts hurrthM ddlers ($100) ' totem.) I cenify this in the perfomuaaofohe work for which dd. permil is iwuad, I shill AN employ any penon in any manner m as to become Subject to the Worten' Compen- g Armin laws of California. Data - - - Applicmr NOTICE TO APPLICANT: If, after making mi. Certificeta of Eacmption, tau should' ' become subjat to me Workers Campenauon Provisions of We LAW, Cade, you must nmhwim comply with such provisions or this permit shell W domed revoked. r ' CONSTRUCTION LENDING AGENCY 0 I hereby affirm met mare is a connuucuon lending Agency for me parforomme. i f Z y the work for which Ni permit is issued (See. 3097, Cis. C.) - - - ww Lmdre, Name rLender'. Add., - I certify Jut I have mad dh ppl rl end mum mat tW above infomution is , careen. I agree to comply wish VI a ordineroae toil suer lawn relating to C.i 0 building construction. And hereby a nwlives of skis city ban¢rupon the AWve -m rdaned property for inspenion , - Lr. P (We) agree in save. Indemnify an keep hartnl4a me City of Cupertino ageimt U Iiabilitia,judBment.,loss end sapensa which may in Any way amom.8asia said City �. W in consequence of the ghnf., of this permit. i, N APPLICANT UNDERSTANDS AND WILL COMPLYWITH ALI. NON�POINT C.7 Z SOURCE REGULATIONS. a . (L - r SitamaufApplicaroccorutor Dare JOIE - ✓�'N7,911/( IC'.0 ere %®1 - �'� 7a. 5 �. HAZARDOUS MATERIALS DISCLOSURE ., Will the applicant or future Wilding occupant tone or handle haaardeus material, Re -roofs As defined by the Cupertino Mu t a1 Cade. Cter 9.12, and me Heath and Safety Come, $.Jm2553z1a)+ Type of Roof ❑Yes No A, Will me applicant or more Wilding occupant we mp,ipmem or devices which All roofs shall be inspected prior to any roofing material being emit hourdaus air covessm s defined by me Bay Area An Quality Mancmrn egt installed. If a roof is Installed without first obtaining an inspection .' ❑ Y<a. I agree to remove all new materials for inspection. Applicant d Ihavareud a= rommoneriatiewl.irementannds,Chis 695 of the Cah- . understands and will comply with all non point source regulatlons.- fmua Hal r r/COde, SuvgolLm)2 505.255J3.nd ]5530.1 nderstatd my if the ',ef omcngjrcmnAlym�o ebdnypm �rtpominility owacypt te9 M ysu ce of d Ca df ,rpad'D/� g V AVII I / Vi/ I Signature of Applicant Date .gent Data .. All roof coverings to be Class "B" or OFFICE