02050079. _..h: .. ..OFFICE... _... _ ....
` CITY OR CUPERTINO
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smt.nmc ontston," PERMIT
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CONTRACTOR INFORMATION:
BUILDING
L 19SDRESS:CULBE RTSON'DR"";'-,
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PURE ELECTRIC
PERMIT NO. ..
02050079
iD DAVIS
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27365 INDUSTRIAL BLV-
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PHONE:.
(800)246-9998
SANITARY NO. CONTROL N0.
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.ARCHITECT/ENGINEER:'BUILDING
PERMIT INTO
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BLDG ELECT PLUMB MF.CH
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= LICENSED CONTRACTORS DECLARATION
the ny ffumthat lamlYe-ed d provisions ofChxp¢sec m ing
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CAP OFF '.LIN
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a-imSe<u ByoowafDlvsa'�nfro a tics ndarif,so ,nate dmyrasK
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GAS.�kP�E�INSTALL.:
''220' VOL
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FOR RANGE .
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" ARCHITECT'S DECLARATION
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1 underst5nd m 1 II heaved io records
Y P-ansh a public reco
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Liecosed Professional .
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.-. OWNER -BUILDER DECLARATION
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1 hereby. affirmaffirmthat 1 am exempt from the{onwcmr's License Law for the
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following rcainn. Section 7031.5, Bar inc,s and 1'romc,imi Code :'Any city or cmumy
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,' which requires a permit to construct, alter, improre, demolish, or Blank arryinnicame
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micur t is 1 qu re th pile fin,suchnpermittfleaspwdnatem<m
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Sq. -Ft. Floor Area: �'"'•C
Valuation
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licensed
that n<n" p a t the p i. m nn ContractorsL' W 1Chap¢r 9
(co C.S with Scl ]0W)of D'i.o 3 Rh B. eu andP feu Code)
Doti the s exernpuh b. f
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rcfrom aneE th alleged exempt o".Ay ninon
5360'23
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.::, of section iO3L5 by anY applicum for a ce it suhjccts the ppl cam m o nvd Penalty
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APNNumber'
Occupa
OccupancyType
❑I of .1ympioye<: m gaoam�rsni<cnmpemotion.
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304 — ROUGH ELECTRI'
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walla win k d the m t re rs nm'n¢ tied- offered Por sale ]Sec ]044,'
'Bu restitin Pro ns Cole. The Com t s L¢ense Ww d«s not apply to an
501 - FINAL )•,+T,y+(•mp�ct}RG
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cos-c'.111.
omm or progeny was balms tar imvrovea tnercmn, ane wino a«a aaen work himself
505 — FINAL ELF TR I CA
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or Nmugh browemPloyeea, provided that such imprnvcmems are not intended or
acted or sale: 14'M1 et the building or nnprovemem "IJ ithin oneyear'of
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canthen will nave the burden of proving that he did oat build or
imp f p rpose of sale )
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`P Mny ,ely tcang @ I c sed v
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project
c w t the ProJut (S ]Oaf Business tin P f u u Cod '1 The C manor's
mans
UeetrucLiosdashisiY t o iter f P ceny h bu Id ....... themmi
Q,aml whto o act,teenef.r such. prole,,, with iicomas dq Incensed pursuant. m.tne
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i Coh me T' Le Law.
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t p dcr5'. &PCfonhis reason
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WOUP ATION ORK DE ill”.
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, J^pcnalty,of pi one of the following declamuons:
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I,ha4e and will'maimain a CeniG<am of Consent as self -insure for Worker's
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Compensation, .,-provided for by. Section 37M of the Labor Code, for the
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' performance ofine work for which this permit is issued.
O 1 havermul will mmiTcrWkc?,CmaI;cm.ticTn frimmice,ti, ic,ui,,d by Section
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37W'ofthe 'Labor Code. for the performance of me work for which this pewit is
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sued, My Workers Campensation brour6nce carrier and Policy number arc:' '
CLIer Policy No.
'CERTIFICATION OF EXEMPTION FROM.WORKERS'
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(Nis(This ctmn n <a not he completed if the pews is ror,ome hundred dollars
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�'r 1evartly th t'. the P d t cep f 11 - k JorXh h ihpew�sf 'AQ
`Kan t r nY r er t ec�j<�P�/�karsl
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NOTI T A 1 Ifs !F Ta Ei-' p —m. y n jd
Woke Cmpenso,hi p fth Wbm Code you must
-bedwith 6m
forthwith com
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• ply with such prv. s ons .,,his pcwn shall beemoted vokcd.
CONSTRUCf10NLENDING AGENCY
h by R " that thenswa,o id' g.,c ry far the perfowan«
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of the w�rkforWbch
}Land ,N '- ..,th pe t ..0 d'(S 3W7,Cis C) •:
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LeindelsiAddress- '•
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tUmould
fr.r flIcit fYThan lh c d Billapplication rmdtma'but the abovef m
correct.I gr e m omlly with II itY and c tY, d' w d st m laws rel ung
grnnsmucnb and Im bJaothositfesof this city, enter upon
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fthf abo en tTissed pen fro Tp
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(Wgee to s a deme fy and keep hummesdre City of C peri d against
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Ci, 1, J dgmems. costs d expenses which may in any way accrum. against said
.Cary q<c of the8 foe of tN' wit:
A CpNTI 'D 'STAND. NDt-COMWNWITH,�L�N POINT
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Issued b !
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Sigmota fAPPbcanUC ^"°
Date
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mrnaor ,Date
Re -roofs
HAZARDOUS MATERIALS DISCLOSURE'
r" Will the applicandt 61 future Wildirig mcuparn store m harafl, IT".,mamnxl
'as def
Type Roof
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rd b) Ne Cupertino Municipal Cod Chapter9.12, and theHealth and s rely
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1111 roofs shall be inspected nor to any roofing
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,, wnm appluamn f t b Id g occupant seequipment devices which
it h as d e r coni r as defned be N Bey Arca A r Quality Manage ent
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If a roof is installed without' first obtainin an inspection, Vagree't( remove
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all new materials for inspection. Applicant understands and will comply with
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- I ha d;'Ne licard i'mmcdal q ;mrrmmv under Ch pter.695 of The
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all non -point source regulations;-
California Health & Safety Code. Sections 25505, 25533 and 35534. 1 understand that
T the bild'gd« tcrtetlyM1 roti tthat t' yresponsibility'o
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"cu f,h t 'rcgd requirements
r tttmy
. which tP ,sum fJf nficam of
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Signature of Applicant Date
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All roof coverings to be Class "B" or better
. Owner athm ized agent Date
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