00120135 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING AUDR[tiS: P iRM11 11.
0t 14 NORTHGI_LN Sn ALTON AIR CONllIl"IOhIIki� IITG00121b135
OWNERS NAMEAPPLICA'T'[ON SUR DATE
RICHARD ALFRED A AND At FF ED A 45317..10 7NDIJSI"RIAL OR It4 !?/81 /20P10
PHONE: SANn'ARY NO. COMIROL.NO,
(510) 490-5655
MOO ARCHI'rEC`UENGINEER: BUILDING 1117RMIT INFO
PL1>C EL[Cr PLUMB EC
ca
y N LICENSED CONTRACIORS DECLARATION
�0 1 hereby arrt...lira,I min licensed odds provision,arehapter 9("rmmnnciny Job Description
wl_.w with Section)IXXgof Divisin 13ol the Businc,,mrd profession.,Crde.tind my license
fix_1 irmmurorecann £ �� L� REPLACE FURNACE
rc ¢ Licens9
5 LL N
are 1/ 'Wf%Tf COnlmelm _
¢ ARCHI'TECT'S DECLARAT O
I nnJcnh'nJ my Plnm shill be useA a,pnMlc rte '
R Licensed 11mtcwitmal
o�
OWNER-BUILDER rI ruin I DECLARATION
1 beaky affirm that 1 1. cBusin from lac Cession,Cook:
License Law for me /
t a following rere.s a IScalnu 7(IJLS.Business and Profession,demolish,
h, it Any city m.xmmy /
ce
`FG which 4 pr t. t 1 I I J I'.h P' Y. cture
ioi it I c,doones,one,In a,hulcmd tor,il,th permit I,111—lilicd,loicauen,
matt ti Apt roti
lothe fervi,loo,ollottl C nrecminlJko,a,Law Chips.9 Sq. Ft. Floor Area Valuai o{I
nith ]
E, eing wSectio00X
7 )al Jnr lair Ra,me„mrd I'ndessmn,Codd $
or that he in exempt thcrcfmnr and the burin for the alleged umnpion,Any violation oe
of Section 703 1.5 by any applicant for a period subjects the applicant to a Civil wital.y
of not mom than five hundred douan 05500). APN Number Occupancy Type
❑l,t A he pmpw,o my employee with wages as mclr,ole corrl'er,a on. 3164.1.044. 00 � .
ohi,v
will ne the oro,and Lha„maam C nor 0o',Li,, IolooldLow tar sole(See.7141,,
-owniness ami PrnfcWhir bodies Crate:The Cnmraelrnk.and%Lew Amro'not ork11joyh rn nn Re -LO Inspections
or thougprogeny Wholoee.)insides Mauch improvement.,
whodsa,swcht intoned or 1"-_04 — UNDER'-LOOR FRAME
or Through his own however.t provided that such improvement ore nm intended or
ccorned omplefm.late. wnowruldewibuavetorurdenonrearm.that within one year or 371. — ROUGH PLUMBING
completion,Meowner-sale.).will have the burden o(proving that he did nm build lir 303 — ROUGH MECHANICAL
improve lin puEsne of.vulel.
❑I.axownorofthe propooy.mncxcla,ivclyeo..lmelingwith licensed....loo,u,rstn 304' — ROUGH ELECTRICAL
conarmci the project(Sec.Inw.Business and Prmex.inne 6vIe:)'rhe Commcmr's
Licen.a Law d«,nal apply ,,an ownter of property who build.or improve,Ines ,a. 505 — FINAL ELECTRICAL
and who contract.to,, .on project with a contninumO licensed ism,mnt v,the 507 — FINAL 1-'L_UMfl I hIG
Commemrs License Law.
❑Lamexeniptunder See, B&Plot this ma'an 508 — FINAL MECHANICAL
ICA
Owc WORKER'S COMPFNSA'1'ION DECLARATION 514 — FINAL P11131 IC WORKS
I hereby affirm under penalty of pe Jury one of the following dcclararions:
❑ 1 have and will maintain a Certificate of Consent to self-insure for Worker',
Compensation, m provided tor by Scmloo 3700 of tiro Labor Code. for the
pcdinnn'ncc of tau work to which This pomtit is isucd.
❑1 lmvomrd will malmin Worker:C...u1n,stinn Insurance.as«yulnd by Section
JIIXI of.hc Labor Code,lin the perfamunce of.Ire work for which this permit i.
issued,My W'orker's Compen.se.ion Insurance camierr-and
�Policy
_number m�e:
Carries`(/?n,(`-4�J�^5 Pnitcy No,:
(PIiR IFICAI'I(1N 111'1:XtiM I'I'IUN IBOM1I N2rN KIiRS'
COMPENSSHON INSURANCE
I"Ibis r«rion need not be comple¢d it be)emir is for one huddled dollars
(5100)In r,.)
I Gerrity Ill:n in the pcdome ncc or the land Iia which this Iwmrit it issued,I
xhull r I ) YY orotter .l hµpm sl b4r1,to the WorkersiI 't ICdt II
Apish
I [Y
APP) I
NOIICs 1
aaftermaking this C r7.rc to onae,rpl red
hoc m . bac.ntothek r Compensation p fthe IaMn oat.....m.
0 � fonhw to comply with such pr this Econd shall be Jnmal revoled
lA CONS'I'RUCI'ION LENDING AGENCY
I hamby affim'mat there ion c u'lowian lording agency lin the pcifonnunce
'of the wed,for which This)emit I,issued(Sce.397,Cil C)
6. Q Lender's Name
7 7 .Le,mbe,sAddm.o
U C I certify thus l hove cool this appliemion slid,late but the aM,ve inromration is
P. p correct.I agree to comply with all city and coumv ordinances and stare laws relating
Q C.1 1.toulding mmuucrin i,aid botchy au It... 'cp'mcmasivcs.1 this city to cnmr ulw]l
the bhovo-nmrtu(sned property for mspac.ina p u,....,
f A. (Wo)agree m,.nx,indemnify and keep harmless the City Ill CuNmuouyain.a
(A liahiliticn,judgmcm,,cost,and apcnas which limy in any way anmc against said ^
U Z City in consequence of rhe granting of this pooh.
APPPLICA .(TND IRS NDS ANDWILL COMPLY WITH ALL NON-POINT Issued by. Q '3A/7OA) X� 6 Date
_ La-Z=w
97. L Tic tOnr Dem Re-roofs
HAZARDOUS
.
HALARDOUS MAT,oc'upS n't.no
Lrdmee Coporrmrumor Wildinge..Chaptstore2.and
Healthranmatelot Type of Roof
fined by the 32(mE no Municipal Code.Chapter v.12.and the Health and Safety
CtNc,p r m 255J21a1: 0 No
All roofs shall be inspected prior to any roofing material being installed.
will lie:mph'aalm fill'rehuddogo....la.m use c9uip'nout ordevices wlEm' If it roof is installed without first obtaining an inspection, I agree to remove
emir hvurduu,sir cnnmminanl.s an defined by the Bay Area Air Quality Manxgemcm
Di uic,: all new materials for inspection. Applicant understands and will comply with"
At ❑ye, 0 N all non-point source regulations.
I have read the hamrJmt material,requirements under Chapter 6.95 of the
Call for.I Ealth&Solely Coale.Section,2550.5,255]7 and 25574.1 understand that
if me bolding dos not aun'cndy cavo a tun:mh that'h is my fcnpnn.ibill,m nosily d'a
cnpatn nl Tae requirements Much']lost he met prior It,isxuatme of a Cenifra'e or
Occupancy. Signature of Applicant Date
La I All roof coverings to be Class 'B•• or better
Ownr, thorieed agvat Darc
OFFICE