01050079J
CITY OF CUPERTINO
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CONTRACTOR INFORMATION:
nun.mNG DIVISION PERMIT
If I111.DIN'ADDR""
NO.
/G11PERMIT
V�
APPLICATIONNd IT'j
OWNER'S Ah11"�� ��
P
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SANCt1N'IROLNO,
fI'ARYN(1.
PHONli:
❑UILDING PERMIT INFO
ARCIIHECfIENGINEER:
I )G '.ECT PLIIMB MECt1
LICENSED CON'TRACTOR'S DECLARATION
Job Description
the Yath...i that l an linotwJ under Pnrvi<ions of CM1aP¢r 9(eommeneing
on41.millllliviainnJ of the Ousincs rand Profosinn. cock, and myliccnw
rail fora unA el
I' Ul
L ue,
acne Class
Q/ cfLAR,f17lfM I*A
ARCHnt.SDCC
I undcmanJ my plain shall he uud as puhlic ncordc
I,icatmJ 11n,1 seinnal
OWKEK.BUILDLK OIiCLANATION
I M1eteby .(Sect that 1 vin. the CosLaw fur the
Co e: Any ccense
vml Professionsrrdi Code: Any city rte county
Burin s an
,evwn. (Section 1onstr
t. alter,
whichfollowing
which requires Penner cnmwch aper, impmsu demolish, or repair structure
renter to tela a signed amre'tent
requires thevistan ant toe asgned
nleo rt
prier m its i re
Sq. Ft. Floor Area
Valuation
mensnm, Cah
Jtathe ialia'ttncdl in pnwliiisinfthe Rmtmnnr.Liccmclaw..as
Secti,ttame
Coe)
wish of as Cnlc)
Division 3 w'tnc Betaines. rand Pin,
i,
at thin he c thc.n .i a e Any
thalleged csempno o Any violation
is 31.5 bt tany a fi and the hack for the subjects
m mm Section eons by am for aPermit cuhjats the applicant to.civil Penalty
of
APN Number
Occupancy Type
main.
o(nrn marc then Bvc hundred dollars ($5 00).
fee hu dred
❑ Lac owner of bhc pmPe"Y, ur am eng,loyee. wi It wage as then .ole mmfna'aflon,
Required Inspecti
will do ate work..na the xwcturc is ,at intended n, offered In, sale (Sm. 711,1,
Bovine,, and Profession, QNe:'Phe Contractor's License have tires eat apply in an
owner of property What builds or impmves thereon, and who does such work himself
or M1ul own inn proved,) that such improvements me hot emended of
/ /k
erectdirough
revi,. the is sol wlmlm one year or
ofla"Ic an sole. If, boweve,. the huilve or Ind"' t,,
/
olmem
the,
will have the huNen of proving thin he Aid not bullA ter
t
bhainve
iprove
n-nuiWer
improve for Putpane of lois).
for
❑ I, va owner of the property.... exclusively contme,ing with licensed conwcmn m
Conuocmi
O /
conawa the project (Sec. 01114. Business and I'mfe.ssions Ctxle)'ITc s
license Law Anse not apply w un nwnc, of property who mid—or iranowes iharcon,
inti who commits for such projects sols a umunemr(s) IICvavCd purutnt m the
Cr%mvra's License Law. , If & Is C for this rcuum
E]1 inn e..,, under Sec.
Owner Uam
WORKER'S COMPENSATION DECLARAnON
I mrehy of inn under penalty of perjury one of the fallowing dedi mtiaus:
❑ I have and rill maintain a Certificate of Consent to self-insum for Walker's
Camrynsation, us pnoided for by Section 1704) of the labor Code, for the
pvrfnnnanen al the walk fur which this permit is rowed.
❑ I have and will maintain Worker's Campensmion Insurance, as rcquire) by Section
371() of the IaMn Code, far the performance of the work for which this permit is
icmed N! Wo�rkMs/)1CC�,mpea aalmnn�Innsurance emotiveand Policy .number am:
klar-
nrricr�Vyl'.R I II'I� I�Oit/CiV%f',MI'I'ION I KOM' dRKI>RY
,C
C(1MNI'tHNSS11ON INSURANCP
(This section need not be completed if the .it is fortune huwrtd dollars
(Sikh el le".)
, I,,r nm tut the work far whine min permit is ir.wed, I
1'cridy thin In mp,,
shall not employ noversan in any manner so a% m, hcvnme subject to the Workers
Cmnpcn.wtlon Law, of California. Umc
Applicant
NOTICE TO APPLICANT, If, after making this Cenifcme of linenpulso. you sWawa
hecontewbjecl to the Winker'. Cmiga'n.vaonnlw rte (lithe l..bor Cade You
I ,amply wiat xnch nrnvi, l ter titin pmts b .hull aid -lard nevnked.
y CONST RUCTION 1,P13ING AGENCY
I lrceeby affirm that there is a constructed lending agency fire the performance
of the work for which this pemat 1. issued (See 3097 Col C.1
[arder's Nam,
Leader's Address
I certify that 1 have read his application and state thin Inc obmc information is
rmet. I agree to comply with all city and county ordinances and state laws relating
;) m building conslmclan.an,] hereby intnorire representatives of this city to enter ury,n
the above.menamtnl prapery ter inspection Pape,,,.
y (We)agrce bustle. iadcitual, and keep hi it... me ciiyot Cape."", against
W liabilities, juJgneme, costs and erp,nws which'tiny in any way .ecru. against said
/ ��/
Z Ciry in conxquence of the grantingof this pe.,at.
AI'Pl.lf UNU"STANDS DWILLC•••low'''!l�'''�'w'v��,��1YWITHALLN0%411N/T
E R GUI:: O. S. f/i/'1,/I,/
Y
Issued by: Date
gar,IAP b/Lnnra, —
Rc-roofs
IIALAbi IUS M 111 IAI ti DISCL(ISt1Rli
/ Wit th a ereada¢heldmgtecupnssmrearhmJlehvallouamatatial
Type of of
v. Iefio by't uNo no Municipal Cole. Chapter 9.12, and the Health and Safety
Cr ,. ce,ion25532(c)?
❑Yea El No
All r fs shall be inspected prior to any roofing material being installed.
pal ipbrent tar devices which
If roof is installed without first obtaining an inspection, 1 agree to remove
will he aPPrcara or am Wimiag,a�c-Paula'=eq
enth h:umdous mrcamamirep, as defined by me Bay Arca Air Uaahty Managemcm
a new materials for inspection. Applicant understands and will comply with
n:atn,tore. oNn
a I non -point source regulations.
I novo bead he ha'a"I is nun enols regtdreaents under Chapar 6,95 of the
Cullliania H.10 & Safety Corte. Sections' -5505, 25533 ad 25574. I under.taad thus
if the building Aoe.e not curse dly have a ¢nand, that it is my m,our,ibility m, notify Ne
re,
ernpam of the u tomcats which most be r ,, usnance of a Certificate of
Signature of Applicant Date
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EAmJ
All roof coverings to be Class `B" or better
.gem
OFFICE