00120003 ,
CITY OF CUPERTINO,
BUILDING DIVISION PERMIT ,` CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
J
101159 S. .BLANEY AVE.; 1r:Y ,. :.r'0U1cQIk1tZ�?
OWNER'S NAME: APPLICA'1')ON SUR DATC `
Ilk .TOE NUCCin,-.. �+: ,..- r �.x 1.01-42000.
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HONK, - _ - SANI"I'ARY NO._- - CONTROL NO. -
O G z0 ARCHITIiCI]IiNGINF.ER: ° - BUILDING PERMIT INFO
w p - BLD ELECT PLUMB MECH
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LICENSEII CONTRACTOR'S DECLARATION
z 5,p'' lhemhY arum nhrn anh u[ensea burr,prmnlsmn,m draper s femn�nenc; ' Job Description -
-FwCly wllh S,,nor7000OfDivisinn7af the Nosiness and Pmfassinns Cude,and my licame - '
S is in full Same and effect.
r�< Licloo,Cla,. Li[.x SWI«TCH',ALL,-.ON-SI^T�*ttSrIGNSr
h
a Dote Contmator
3 O so Adictu'rECT'S DECLARATION
yp� ; Inn(...rend in,pl:mx shall be uwd us public record, .. , .
y a.O O Lice nsnl Prolcssion°I I •, -
,oho, OWNER-BUILDERntf h.ARATION -
1 heathy affirm that 1 am,Basin from the Conions C's :Anse Law far the
F Z a following ral.,a(Sermon 703,5.n,.[b,>an rI'mfesaiyns h, ,, Any city or roomy
Fer which 4siLl p tt [ t t It p d I M1 rp'ir Y.tm hoc k _
FF p i- a pill II I II y Lt'I int -
- .roll r with
I torso p o f t , r I a l'p' l S PL Floor Area - ' Valuation
fe h he by w apt therfroolllp of a hh dill lM Bit alleged
c,and ion.A ane CaWl ' Sq.,Ft. -
or Thal he is 31.5 b tang ap li and the bansin sthe alleged exemption.Any l valor
of Section a than by any hundred
d ll for a pemhit whjers Inc applicant m n civil pcnahy
arant mme man evenaidma aanars(ssfhnl. APN Number Occupancy Type
Ell,its oenerorine properly,ur my employees with wogeraa the'usolccompensatimn, ' 71
.'
will to'Is'work,and the xnncutre is nm Inloudnl or nalic,fir late11ce. "In't, - -
posines I I Profession,Code: no,Con,rotor s License Law da;,not apply to an ' - Required Inspections `
+ u I'p pry Wh builds p tl d h J hworkhm.sell
Orli id his .ppirlo,ca,providld,lobown' p I, intended ir - 10.0 ,7—,FOIJNDATrICIN '
oro red far side.If,he a cr,the building hr hmprovemem .old,thin one year of `—
iontplelion,the owner-hwlder will have the burden of proving that he did not Mrild or ..,1103-—- UFE R,£_.. r
ron r lirn f: 1. is
-'int 1 ,y " eln� Iv r r g tl I' -I ri.rhh - .I i104ags + RI BAR,, - '
andconstrict lh[project(Sra ]aa Basin,,a,it Inressmn,Cot The Collector. � - ] 05y,= .ANCHOR It BOLTS '
hLawdoct,farwith ere,wth.eienywh(noe,oeirnnrovasttothe wg31Zt4r,j—' R000H-'ELECTRI'CQL- 4-
and who nm iesc (or ahch a won a ttmvecmr a licensed unmet a Ilhc -
OOlorocoaalsuvd,,Site 11&PCfor this reltme
• Owner^ plate 5.1„4>�j—,,54,,4& PUBI_'LC:dWORKSMk:..
i- - WORKHk'S COMPIlNSRf10N DECLARATION '
I hereby affirm under penalty of perjury,one of the follow ing declarations:
❑ 1 h:nv and will maintain it Crtificate'of Consent in self-insum for Worker's `
Conlpen,alion. a, provided for by Section 3700 of he Labor Code, for rhe
.perRioaneonr the work lo, adi chis...unit,isxrcil „ �at�p����®
❑1 lave and will maintain Warl.ds Cmnpensntin i Insurance,as«yuined by Seri i
3700 mf the Lahr Glide,for the perfomaneo of he work for which this permit is '
lesued.My Worker',Cnmpensalima Insumace carrier and policy number are: MAY 2 1 2001 `
Carrier, policy Na.:
CF,RTIFICA'I'ION OF EXHMI"I'ION PROM WORKIi RS'
° COMPENSATION INSURANCH 1' p�
Thisection need not he replied if the permiI is for one hundred dollars - ”' - BUILDING
1g101)nr lcasJ � '
I lordly than in dm pilli,nnonce or the wed foF which this permit is issued.1'
sh II I P� Y Y P r h o yl' '. I be hl I in.Ili W kers - ,
Co p I iL IC II 1)
NOT[a t
NOTICI I j APo the Wo I II h k g his C provisions
at pt Y u should
Oneem uhab,l theN Worker's C pe I 1 sof they M Ceae you hurt
forthwith uh nilly with h p ssiom or Ili s Perri t shop hu declined revoked,
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y*, COI thineUCa ION"n'LI"i i l G AGENCY
a 5 w 1 horchy'llgml rlwt prop Is u conal(Set. Icnding agency I'nr the pirfarnnrmx h
of the work lin which this permit is issued(Sec.7157,Civ.C.) s/ /
L z ILed Adde,,
7 _LeAdde ,
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urtrthinlli radio, 1 t
is
c1I,yee I ply II 'tyair I ty Irtwo,and,late I 'bell III,
n d gan hsacf. ulhcvhy,tth .pre mfve hnhrsdtymehle pa �tgranting
'
-
h h I bed..property pe1 rn l(W)ay a ' d ill ass the C ng'uI
it 1 dg t and peroo, hath my inany wayccr.IitaA
7 City re of the g t g f this pennit.
SOUCANTUNDERSTANDSAND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS. Issued
edbY' s b-ate,`)
'
Slgn:mrmof A,,I1,crVCmmrtmle, ,•..Date 'Re-rool'S ° .-. • - .'
HAF.ARD(IUS MATERIALS DISCLOSURE -
Wit lthe.'heantorliaoabrilliingocarpam
nlseeorhandleabandouaalenal Type of Roof
as defined by the Cuperim Munlcipa Code.Chapter 9.12,and the Health and Safety -
-Cade,Social 25532(a)? '
°Ye, ❑,Nm "- All roofs shall be inspected prior to any roofing material being installed. '
Wilinenpph[ahnh.rrirnrcladdingoex...can re,cynitim.mmrdevroexwnch If roof is installed without first obtainilig aroinspection, I agree to'remove
emit hamrdoux at,cmalarbillalls defined by the Bay A.Air Qualify Maagemmnt -
Diaricr^ all new materials for inspection:.Applicant understands and will'comply with
°Yef °Nn all non-point source regulations.
have read the'hozardous materials mqummments unda Chaluci 695 of the
Californi i Health k Surety Galc.Sections 2550.5,25533 and 25534,I understand thatit the llltllrg dna,nal elll'I'CIII yIhaVaalCI1WI1,l Rat It l xmyor"'i ,l h iln,lonmllfYlhe
ttnTion It'he m4remp m
uicna,looust he met prior In manatee ml ni
a Celieno or +•- r '
"`l"°p°°°` Sign.uure.ofApplicant Date - -
0%nor mauthorized agent Date All.roof coverings to be Class"W' or better
.. • - OFFICE -