00120136 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
IIUILDING ADDRESS: PERMIT NO.
C,
OWNIiR'S NAM1;� .a APVLICAI ION Sthd DAl'1? •r'y
J)dl ' ' " SAN11ARYN . C(N7R CNO.
❑z% ARCIII'I'EC'I ENOINHER: BUILDING PITRMrf INFO
O RIMCI IiLECT 1' 1 1 MliCll
ce I—_I I� I: - 1.I
LICENSED COMIRACrOWS DECLARATION .lob Description
ni
I herby nnn mmA nn
a,I am I;mAer pnwisinm of chapter q(commencing P
with Secliors 7gN8 of Do kion 3 o1'he Holmes,and Pmfe,s;om Code,tend my license
in hull limn and effect.
C w 6 I5;cdmc Class p.— L;c.4 '�y/�L
�3LLF Dane-1,2=7,1=nr}7— canincurs. Fi�_r .,,„. ADDITI:ONRL GAS LINE
aa=O m ARCIb I'FC'I'S DIT:LARATION
g1 understand on,plan,shall be used ns mhl;c record,
Ix+'alp 1O Liccnw W limit eoinitial
n a OWNER-BUILDER DECLARATION
ar 1 hereby:JBnn that 1 tan exempt fro,,the Contract"r'%L.icemo Lw,for the
I'ollonving remora.sceiion 7131,5,Bu,;neve end Profusion,C«tel Any city or county
N F G Mach oc,oims a lionoit alte, ripalt - dr, li,h,,,, p y an,eu,c
of I' aI t " a1.' v IN I'I1 ' Il 'hP t u 11 if u
datnn
math I 1pm,ta n m n o , I lac t +or,l L'w Clai'ma 9 Sq. Ft. Floor Area Valuation
monm'encmg with Section 70W)of Division 3 of the Bushes%and ProRrsions Code)
or that he is exen'pt therefrom and the basis for the alleged o,minnion.Any violation
of Section 7031.5 by any applicant for a pam,it wdjec,s the applicant to a civil penahy
of not more than five hundred dollars t551Nn. A PN Number Occupancy Type
❑Ina cof the propert...... y anploycc with wage,u„helr sole compensation.
w111 do thew,ak,and the al...are;, tot imonded err olicnJ fur lute(Sec.71144,
Bovines and 11...tell ions Cod®Thu Contactor,Lktnac Law does no,apply to nn _ ciIuired Inspections
arr of property Who build,is onpnwe.0,creon.and who dew, urh wort.hnnself '
brought his evil employees.provided to.,such improvements arc not imended or _
offered foram.If however.me Wilding of improvement ,uld win'm one year of I OF, — SEWER R. WATER
R
comdon...@e vesom,_huilderwIli have the Immon of pmving that he did not build or
iimprovefor,purryn 20 g — UNDERFI OOP. PI LIhILaIMG
❑La.owner(it the propertYan,eclnaiveycommingw;thrcer.cdcontractors to 301 — ROUGH PLUMPING
n"Imet he P oNct(See 7044,B00000.and Proma,;on,Cina:)'Ihe Can,,: = ._ TIJ9 R• 0 R SHOOER
R
U"Ime Law Joe,,at ally to an elect at vol�ny who builds(it'Imp ioc,themoon. - 302
and
whorl 1'.let, an such p...r,a,wi,b a corhaocm,) licensed pmwam m the
502 — FINAL PLUMBING ENERGY
❑Ian"exempt ander see. H&Pcrorthis written 506 — GAS TEST
0xnC1Dat` 507 — FINAL PLUMBING
WORKER'S COMI'1?NSATION DECLARATION
I lNooth,'ll under psarally it er1 Yo of he billowing&d.,,ation,:
.] 1 base and will maintain a CertifiCILIC f Consent to sell for N rla r'.
Compensation, provided f by Section 3738 I the 1 M CMe fa the
Com en ,a work f Itch d :pen n il illamd,
❑1 have and will mamlmo Worker',Cnmpcnsauo"Insurance,as required by Section
371N)err the Labor Cole.for,he[w•rfmnwnee of the work for which,his permit is /1
listed My��__Woo_rrk��''er',C....
i,inna"i/on Insurance carrier and Policy numher are: {/^
L'arricr./�FL�,a.ivy._(,�c.l'nlicY Nu: (�sf �L�II 419)
IiRI'11TICATION OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need no IN completed if the permit is far one hundred dollars
(S 1011)or le"')
I ecnity sunt io the pcibalo nee o, IN work lie which,his pemdt is issued.I
shah nm employ any purnun in m,y mnnne;vo as m hcaonm,nnicsyu,ere woAcO'
cel„pct„ado,I,nw C.tli n.D:IIC_r7_ Z!- U/
NOTICE TO ATLICAN r:ri,Coafter mak;ng,Ms Cenifi s o of the Labor i n.ogle.y should
mst
bWcaw
forthwith
comply
a,the Worker',componwnon provisions of me timed moral you moat
� Q hmhwi,h comply vim such prari,ion,or this Penni,shall M:Deemed invoked.
CONSTRUCTION LENDING AGENCY
a > 1 hereby alarm non mere Is It congmmtion lending agency for the performance
W
of work bar,ed,fill,Damn i,mord(Sec.3097.Co,.C.)
ALcndcr's Nan,
7 Leader's Address
U Q I I agree tom l have real alis city
application o”anal sm,e manila d stat %yea information is
C) (•” coma.I agree a'comply with all my mW county ordinances whi state lows relating
[) tabu;Idingc,malunion.and heoran,phori 111"cmmives of,his city u'cmcrupm ,
y W Inc abn(We)alllicea,)pmlenY if.,li Ikepamdxs.
F 1 Iwc>upree m,eve imlcnmify tend Amp hnr...y n l he Cly a,,na, against
V1 Ca,Mics,judg;toms,edea and a Oath xbich m:ry in any way;teens againu said
U C'ny in cdnseyueme of the graining ill thispars
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT ISSUCdb)� Pe. /T•_���W�� Date 1.2—
SOURCE REGULATIONS.
Signature of Applican,/Comncw, - Date Re-roofs
HAZARDOUS MAT ERIA DISCLOSURES
Will Ili,:,,,beim,or four,heiman,ce,Pam nom or haandle h,,a-man,material Type of Roof
use ddincd err me Cnpcnino Municip,A C; o.Chapmr 4.12,cd the llc:dm nnJ Sdcry
Coda Section 2553408!
El W, All roofs Shall be inspected prior to any roofing material being installed. '
Will the applicant orfumreFit,Jd'" ..cupontuseem,il!nmtordosaee,wmen If a roof is installed without first obtaining an inspection. 1 agree to remove
emha
it raNota
aa r conmminama as def Jhy the Ray Area At,Quality Managemem
�DishmB all new materials for inspection. Applicant understands and will comply with
°Y°° all non-point source regulations.
1a lIII h N 't ; y f: nil (1'Pf —1 Olde
Culll II 'lll kSaf lyCd 5 'i ,2558545533 Ie_SSW I J rnJ mut -7 �
tl
occupant
l a I hi tan l m prix y rcvP 'b'l y t tiff the / [l ��O
cecupam u l thus requirements hick ,1 ,p to'.wit f C n hcam of
tN"`Y' Signature of Applicant Date
Ow or 51" le "li All roof coverings to be Class "B"or better
OFFICE
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