00100199 'CITY OF CUPERTINO - 5 - "'" ;,—x -Y -
BUILDING DIVISION PERMIT CONTRACTOR INJYOORMATION
.BUILDING ADDRESS' - -soPBRMI3 NO. ;my . P
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OWNER'S M1 ':� + APPLICATION SUB DATE
I — ^ ' ., :
(INF.: _ SANITARY NO. CONTROL NO.
1� peZ ARCHITLCIILNCINFLR J, BUILDING PERMIT INFO ,^
'BLDG ELECT PLUMB` MECH
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- 1 ICFNSFD CONTNACIOR S DI CI ARATION '
z 5_� I b b -'' Job Descri tion ,
o Z�° Y ff Inn ed 1 P n' f Ch pt 9( me g 4 }1 , .
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some
<F< wllh5 t 9(IOID rrry�s9lnl the Bu dP(�f_i�} 'C d and my license
As�6 Lanf IICI at, lJ'`�. �U. -
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ARCHFFEC[ LARATIO
1 ae d rpl : bill .el p bl eeays, WRTER; SERViICE REPIPEr
OO Liveed ProEssal on ` •, _ .
°ies OWNER-BUILDER DECLARATION _
'e 1 hereby arnan that I am exempt four,the Conhacmr'.Lice a Law for the •.� -
C y roll oay e' pe(S f 7031.5.H " 1 Professions Code.e y 'ry county
$� ❑ wnl b n ..,true, h p d I'1 p' any ar caro.
prt in t,is....as,clou faminesthe pl l;rdna an such ptier fl 'bneJ sl lemcm � _�� •^ '• �
thou lie is licensedp t in the provisions oft Contractors License[-u (Cn zero Sq. Ft Floor Area, Valuation
monamenang with Section 90x)
l Business- d Professions- Code)ortit[it it r d the basis f the a pli Any violation
pi9031.5b yrrapathj,v,,ha aptriaevivil pnnhy
bfa t than
five handled dawra(ssno)
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APN Number_ OCCU�r1II`
01 or that, early nr mYempl+yeev w'Ihxvges oslh ' . Ic alinm C. pe ,'•'
will d 0 k d II s s t intended uttered t I (Sc 7044, � � '
Busirec,add Podisvion,OdeThe Connector*,License Lowdoo,,n ,apply In an KI VJgoired Inspections
owneror properly Who h�lds m'npnvc,Ihaol and who dyes such warkhmself , 35QI
71 ] 2QI.or through his own employees.provided that such improvements ore not intended or .- -
offered for sale.If,however,the building or impmvemenl is said within one year at -
omplctilonf the
iweohulleerwillbaseliehardenal""provingthat he did not build ' ., 1.06 — SEWER X• WATER-
1
RTER -
in,eac papa ., + - •.
^711 flha Pro,fortlyant I exclusivelyconnecting withl .ed tactors to GQI'I,'t ,'^ UNDERFI_00 R ;PI_I,IMBTNG
1ons t in police,(S .4(94 Bas nes Profession,C de:)The Contractor's '
.iecmeLawdoesantapplymancwnerofra.,lywnobnOdsorilnpmee.mem+m. 301, —' ROUGH PLUMBING
and who contracts our such poLegs with a mnhacni licensed pmatlanrto the 3Q12 — TUB & OR SHOWER.
Conlnslors License Paw,-, , .
°Into exempt See. + ',B&PC Bu this reason 502 ' FINAL PLUMBING •ENERG Y
.;ow�ler, nate 5GEI — GAS 'TEST
'WORKER'S COMPENSATION DECLARATION -
' Ihereby afnnunder pawltyorperjarynneollhefollowing dmmratinr 'FL
s. ,507 —. INAPLUMBING -
] I have and will maintain it Leontram of,Consent la Selhinsmc for Worker's
Compensat r, as provided far by Self inn'37M r0he Labor Code,'our the •`e
purfurmamc of the work an,which this)moil Is issued. - -
O 11 J Ill mint W k C 1 f 1 . q d by Section
' ' • r C/�/� ^
3900 of the Labor Code,far the perfornamad of the kir which this pearmi,isis
, nrri�y WorkersC pr, l 1 . ra uer'dnPo_l ynunber are:
CPolicy,.
olicy rrd�p
q
CERTIFICATION IXI tOMWORKERS
COM'LNSATION[NSURANCE
(This section need not becompleted it the Perm'1 Is For a hundred dollars
(5110) I".)
- 1 certify that in the performance of the work tar which this permit Is issued,1 - -
shall not employ;my'",mn in any manner so as In became sabect to the Workers' R
Cnmpensmian Laws of Ciddonna.Dam
Applicant
�- NOTICC TO APPLICANT IL aflermaking Ibis Ccnificateef Bxempllon,you should
Q Obecrnne subjmuo fac Workefs CompcnsTnion ptov Bions of tho Labor Gale,you moll
fortbwhh comply with such provisions or this pearl[shall he domed revoked t '
r
CONSrkUCT10NLENDING AGENCY `• If
• F -
I hereby aB"r n that tl rc-o wuion lending age sy for the
partial - + " t,
> of the work liar which 11 pe i s issued(Sec.3097civ.C).,, L.
_ W Q Lender.Name d6.
z' Lender.Address e S .
I en'fy
Un. I J- t' tit nit b f tI
Isewp1Y will,ill city Laid alumina.,and t I ing:abuildingconstruction,dldnerehYartho representatives fth'scY taunter upon
he b6vi tproperty inspection purposes,
+ Y
' s _
C6 (W)agree to aor,
adem l nPh1 N Cly rCriterionbanxt
d p ,Which air,in any way rearrou uglmm:niA
City
in it at thispermit,APPLICANT
UNDERSTANDS
ANDWII COMPLY WITH ALL NON-POINT +.
-Date - ^'q
SOURCE REGULATIONS. Issuedby: ..l ,,.
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Signamrc of Appleand/Com...at, T Dote. Re-roofs' -
HAZARDOUS MATERIALS DISCLOSURE', _
_ .win Ihe appuranl or rnmrenniming o...pool.mre n,bundle la.ammus material' Type of Roof a . .,`. ,
' ae defined by the Ca'arth n Munlcipul Code,Chapter 9.12,and the Health and Safety
Care,Section 25532a)I
. °vq:, El No AR roofs shall be inspected prior to any roofitig'material,being'�installed.
without first obtaining an inspection, • .
_
Will the ppl r I n Id grepapa6lu,ee��p e I rwnicn If-a roof is installed' .I agree to remove
emit h-:ardousaraon ams as Lenard by the Bay Area Air Quality Management ..
District'' - all new materials for.inspection: Applicant understands and will comply with''
°r` °N all non'point source regulations: y.
I have d(he hoodod n,.,,(a cals y o n^nls an tar Chlar,695 of the
Cohf rain Health&goal,CodSections 255055533aad 255341 andefund that
lrthe h Id gBvs nm II llyh Iannual hal I y p :hltyl rurality 6 "' p
racen•trFth Iu r It' h test h 11 r 10 wt f Cen fell f t ,r Mai '
Our cY J
�� •Signature of Applicant ;, y Date ,
own allmer r e agent Dine =All roof covering's to be-Class,!B" or better,
OFFICE .