01040084 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BU HAA NO ADURESS: PERMIT NO.
101164 PORISH 121 ATI AR HFATTNG 01040084
OWNER'S NAME APPLICATION SUB DATE
1PHONE: SANITARY NO. CONTROL NO.
❑D O ARCIII'I'CC'UI?NCINHER; BUILDING PERMIT INFO
atm BLDG z_LFcT .UM11 MI'Cfl
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LICBNSIID
OFzmf". 'S DECLARATION U
Job Description
_ 1 hemby that 1 ran licero d underpr oofChapter
j wicM1 Section]MX0).1lDiv,ioJof be Ou,ness art Drrollxsoro Code,amOnyImlose
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nn 101 moan nnJc Qt �'
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1 ek„ yy�'�C�— Lie'"- — r REPLACE FURNACE !yam
3 a y Dae GiC�a— -l—k y S )ECLA _ �`—
a0 ARCtill c wdia,CLARATION qpp A/C. /
C— 5 I undersuuW my plan.,bull h used us public nennl, /7
ee i
ommy
,�++ o O Licensed I'mfeuinnal
n e. OW NI il41f,empl t nn ttLARA'DON
tali= I masa affirm that 1 am cBu%in %an the Comor%Cn Liamse law liar the /
ar z a following uiawe. ronirn 7ormn B,a1w,s and ,l,dmin li Cede.:Any city onalmle
, which requires a permit m mm,gnaa,altca intlor,a h limmit t nr,epairany mlmmmre
i3� prior met,censeac,:,hd For,..I trimw,hcapplicant Ion he Carla air Licenssigne(Clepoem
(commencingwithSeclionnthrprn. isin3oflhcusinesuan.efa.sions cads) Sq. FL Floor Area Valuation
(commencing vwith Sectionlon oro!Division3rfinelit,ld eandion An, i Juni i
,r Rha hm is nips tAny applicant
and the brae,rat ton a1hgM a option.Any l lien,inn
of Section r1th k.5 iv any dirld am for a pe,mn wbjec,s,M1e epplicnm m a civil penalty
lir mummer m.m five na,mma nmmr fssml. APN Number Occupancy Type 0
U 1.it,owm,
it the Pmpvnyo to,cn:ployem
win,,vs as mei solve nlao,mom,
will do the work.and the structure is me intended or rBkred for.ale(Sec.TW.
Boone.,and Pmres.im,,node:The Comraemrs Lmen,e law does not apply to an 3164403'a ec ed Inspections
r ofm
ppcny Who builds or in,pnrm
..m,Ihcm,and who does such wed 1..nwlf
or through his own employee.provided ma,such improvements am not intended rr
offered fur sale If.however,the building or improvement is cold within one year of
plelion,me owbuHer,will have the burden of proving mat he did ran build car 301 — ROUGH PLUMBING
imp,mmr
,we rnr hurpn,e or s,ae). .
❑Les owner of the propcny.ant exclusively contracting witnlicensed mmmem,sto 303 — ROUGH MECHANICAL
Ln,sa'uc,the pnojcmt(see.7014,Beainex,and Ptnre,slm,s Code:) the Cm,Ireelo,•s 304 — ROUGH ELECTRICAL
icl.w Law Jane not apply lit an owner of progeny who oulds or improves memon.
and who contracts for..nen projects out,n eomme,orfv licensed pursuant to the 505 — FINAL ELECTRICAI_
C rumors Ij,,me leve,.
01 all,evamp,uoanr See. .B&P Ctn,Ines ma 507 — FINAL PLUMBING
owner Dale 508 — FINAL MECHANICAL
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury line of the following declarations: ,
.1 O 1 have and will m iumn a Cunilicme of Cosmo ua pelf=lnwrc for Wnlolls
Compensation, as provided for by Section 3700 of the labem Cede, for the
performanm of the work for which this permit i,issued.
01 have and rill maintain W'orker's Comgenwtion Insurance.as required by Section
3700 of the IaMn Code,for,he performance of the work for which this permit is
..aunt.M.yyIlW,nr�kc(r/,'.x�y, npmnsutlon Insurance runner anndd Pol icy nntnheram:
Carrier�.j�j�9—p6"_policy No.:VlIlj L�n(/ .TC3
CE11FICAMO OF ENEMPTION FROM WORKERS' -
COMPENSAHION INSURANCE
This section need not he completed if the permit ins for one hundred dollar
IS100)rr Icus.)
1 cenify that in the performance of Betwork for which this germi,i,i wrd.I ,
chill nm employ any person in any manner so as n,bcenn r subject to the Wrderi
Coopensu,ion Laws of Coliretnia.Dara
Applicant
NUI ICE TO APPLICANT:IC atler making this Certificate of Exemption,you should
Deanne.smhNo m the W..ker'v Lom,cooation powiomw lirme Lal+or Cnlm,You nmol
Q Q but monply with such......oxer thin permit shall he decnmd revoked.
CONST RUCTION LENDING ACV-NCY
x } m ,ru
thereby alu ,that there is a consetinn lending allmooy lot
ihc Ierknonnec
of the wed for which this pm.,it is ivwed(Sec.31147.Civ.C.)
Q I.cndcr's Name
.z Lender',Add—,
C.7 O 1 recite that 1 have Dad this application and state that the those ino,mation is
W F.acorrect.1 agree to comply with all city and county ordinances and"me lows relating
lwildingcoomorlimi,and hereby authorize rcprewmw,ives of this city to rnrer upon
} (s: mm.bore-mmnirned propery for in,pvelion p,aposes.
F.. 0.e OPo)ago.tame,indenmify and kap hannlc,s,hc CiVef Ca,mi ,again.
VH lnblll,len,judgnanta,lost,and cpxmcv which oily In uaay way.corm ugnittat said
V City in comcy:tcnee of he gaming or thio crntit.
PLICAy}'UNDERSTANDS AND .L COMPLY WITH ALL NON-POINT Issued Date
R114
f IL T ) �2
rg. o npvh t ma�amor Title Re-roofs
UAIARDl1US ATERIALSDISCLOSURE
Will the a"benot or boom ding ocnp:nm,torn rr handle Imrmdrnn o,mcri:I Type of oof
as defined by the Cupertino Mo. alCode,Cilapmr4.12andthe FI.I,hand Saldv
Cede,Section 255}2(.)!
O Yes No All ro fs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant uw equipment lir devices which If a roof is installed without first obtaining an inspection, I agree to remove
emir hmanlous air conmminanu its de incl by the Ray Arca Air Quality Management
Diwier all new materials for inspection. Applicant understands and will comply with
0 Ye, 0N all non-point source regulations. '
1 have read the ne.ardn:...naoriol.mye.tie ems coal,Ch:pte,695 or,he.
Calilornia Ilcmlm h Sulety Code,Section 25505,25533 and 255n,
34.1 end n
if the building ill..ma cuircnty have a wourt.mat itis it,mspemvibility in,mody,he
ccopmct of the recittimmeno when must be met prim to osi once,of a Ceni ficam of
Ov.,om, Signature of Applicant Date
Owner oramnori.e I agent Dam All roof coverings to be Class s•B" or better
OFFICE