00080147 CITY OF CUPERTINO
RUILDINC DIVISION PERMIT CONTRACTOR INFORMATION:
BUN'ILDING ADDRESS: PERh11T NO.
230?-2 VOM AV 1+701+70UJIL�I:FW U, 000801.47
ONL'R'S NAME:
STA'ThVVJ hU1VAH Cr'i NEIR 4ALI+fiTO WAY,
UNI;: SANITARY NO. CONTROL NO.
G K 2 ARC'HI'I'CCUGNGINEER: BUILDING PERMIT INFO
WU RLI GLI hC1�6UM�.MCC1�
Fz
LICENSED CONTRACTOR'S DECLARATION Job Description
O G 41 hereby mGrn Ihw 1 am licensed under provisions of Charm,9 ematoca,ng
wrw x'ith Section 70gllofDlvision 5ofthe 13 u.ines and PwfeWar,Cod,ardam license C.
is in hdl bolero 1� AnnII•rLlhl r0 Fxaarzhl(] (iE,alnh74f..Ey KTCHFJ4,
s a I.i«n c�t ���t�e a_ = nhll) CII FICE
,fir 3 LL y Dare Qom_ Cnmwnor_ _ _
111 l'ECT'S DGCLARA' ION
(=1=O 1 undresumd my plans shall hcred a,public acuNs (/
fWj
u a4 p p LimnvcJ Paul c.,sinmll
OWNER-HUH-DER DECLARATION
427
w I naso affirm Ihw 1 1. ncmm from the Contmcmr's License city
he the
clay
t= !cabling reason ,i rlifnt ]R71 5,It,direr, and ave,dem demolish.
Gree:Any city structure,aonnre
`2 O wnieh requires a e,also
re c ams th 1,uher,improve,h periet i or repair any stmemrc
w 3 to th or I I y th rprcu r t n rectors I is g eJ.wmntcm
sewn dr Itchen i Thecontractors mIr 'Ic,Codo S Ft. Floor Area a]nation
0.mmnhe i escath Section ..I 11 U" r n l this R .' d l f:: n.Gxlcl q' )
or thin he is exempt Iary appli and or Iae,i.hn the alleged tildesexcurtion.Any l petaon
of Scnlnn 1031.5 tiv any dr d doll fnr a Scnnil objects'M1c vpplieam to v civil jcnuhy
of not sense than eve hundred dollars titan. APN Number C;Q,[:cu
❑I,a,owner of the pn+puny.or my employees with wages a.Iheir sale sam,s talion.
will do the week,and the frachum is our intended or offered I.,mlc(sec.]a61, 4G.J r r
Ensures in
wW Prafe,, to Cade:The ContLison Law LisoLaw does nos apply to a II ' nspections
orvr of property Who halko or ial r.,Ilmre I,and who dues such work himself
through his own cloriny Cle.provided that such impmaemcnrs am net lnmaded or
offered rot sale.H,hnwe<f,the building of anrmvemeat is%old x'ebi sere year of 101 — FOUNDATION
t„nnpled...the owaenhuilder will have the thmdcn al'P oving than nerd tint bund or
rrnnc for pumose or sule.I. 102 _.. PIERS)
01,as owner oftncrrnierty,time,elaaivetyemnmona,x'idt)accused coot.,,: m 1.03 — LIFE,
snawct the project ISee.7M4.Rutins.and Plafe'lums CndeO'rnc Cnmmetnrs
cene Law does not amply Io ntr owner of Propery who Haimv or improve thereon. 1.04 -" R4�inR
and who Borne Cl.far.such prancel,with a cenrrialle s)licensed V.,uvnl Io the
Coal In Liceew 1:rx. 101.1 '- (-)NC:L'IOR EGA'S
❑l arm e. 'totes,s e. r1&P C lathe,reason 1.@G S(_1JI:*R & WM ER
P ��//VV����[[••��r''tt1IIII
caner, WORKI?R'sCOMPENS Nil�Cf.ARAI'I� 2W- — 1.11,W-FiIFLOOR 1.C.LA'I-Uhri
I hereby affirm under penally at perjury one of the tallow ung declaration,: 2Q:; 1-11,DI:3&LOCA', l•EQ-IA gV-,AL.
ihave and will araimadn a Ccr'itlme A Consell to self-insare for Worker'. 204 — I.AgDF.F%f1-00R FW-TE
Colnpeasant I, as providnl for by section 3700 of he Lathan code. Tor be 2ki '- LINDF.-il-L00F: I1,ISLA...n'T1U%l
peni+munee of the worA for which Ihi.Perris i.issued.
❑1 laws,and x'ill mainlain W..kcr,C tTeradnti msw,noc.a,te9aimd by section 301. - R11UGH P11".TNG
37h)of the Latour Code.f the perfarnnmce of the work tin which this peruse is 302 -" TLIEt R (R SI'•ICIWI'r7�
issue, Wo�er G lions norm carrier/n�n�J l�'Jnl,'my nundxm se��:��,,,,��,,
Carrier:'211t.41_V.— oli"No,:V`TV-VI OLbt7?71� 303 — R%JGH MEF 1NIC:f-U._
Cr:HTUtCATION01:EXE P1]ONFROMWORKERS' 304 — P[JUC]1`I EJ_.ECTRE'.:til...
COMPENSATION INSURANCE
Thi, reinn need not be completed if the permil is Future hundrad dolmrs 5 — FRAITIE
S 1001 or m..) 306 I`IOI...IM UM3
I rerify thw Ia the Ivedirtnanoe of the work rill which his permit is i...ed,1 307 — I149JLATION
sM1:dl nm valid uny person in tiny manner w+a.Ir becone wbject to the Walkers'
Cam pcnmtus Law,.1 CAHomia.Date 308 SHE:I_I'ROfay.
Applicanl
NUncr:'10 APPLICANT If.after making IS.,Certificate ofEsetordnm you should 307 -` EXTEIUOR I...ATH
M1cca Ic sofflet m nlnrcn
the Workers Cvtion provisions of the I,alnn Code. ".mus,
QO baffe,itheamplyw'ith.uchprot,inn,or'hispermilshallhedeanedrevoked, 31.f� - IhF�iI
fIOh 1_A TI-I
z V1 CONSTRUCTION LENDING ACGNCY .31,1. SCX,A TC:H COAT
aI thereby affirm Inas
as them i,a cohQuon lending agency In,tIctlim
he ...nce
nI the work fnr wlaeh tris.....I i.I...ed(sce.309z Civ.C.) ROOF Id617a_.
Q Lender'.Nanue _•
5 z Lender,Addres :.]<.. — F.T.NAL ELEf.;TR:CCS._ U111-1- 6yv Q 1 cendy that I nave In:pd tri,apphair eaton a „ale shin the above of mrafor is v@12 Ihl6)I_. PL_LIMEt. R3 ENEC EN
arae...1 n ,cum I th u11 city d sown dinznce,and.tate laws relalin
t..i ,,p I,y it y un y n s I •- F. NAL. VECJ-IANICPd- 01111 i'OY
Q (, the idsoin-nne.hwainnandhemhy authurimrcrroenortite al thi.city mercer upon -V�l ,/k p,7J q..
the uboWe)agree to prorcnY for ily and on puHwsc.,. v—e w r r S v ....
F„ a Iwo)agnems:tie.n,alptotdyamlkhihanme,mn wayacmeriaintsaid .:)C14 ._. F J(-V... CiLIJa...nlal(.i liillEly'C�Y
e� to liubilies,judgmm�11.111111 and e,pena•,which Inny in any cavy acewe against.mit I_
z Cityln seyuenleonheswnlr olthis rmiL - ;(�`i — NAL LJ LC'TFiICnL
APP 'A."T UNDIiRs'rANU. A UWILL �OMPhY WITH�AI�L NON-I )IM' Issued b _.S Date
son's'I y .. Y
siyr:rmren Arrucanl/a+rinwmr seals Re-roofs I. r AV In�.�I•f'/t�
HAZNdDOUs h1der,oIALSDISCI.OS ands 508 - 11NPL. IT:_U'lF'hlA4d"IL••
WIII Ine epplicom m limn handing icCmlapt ante or n:dliv hhealtha malarial �I C
a,JefneJ by the Curcnino hlunicirydC Chapter 9.12,and the llcullh and Safety •Jp '.- „
Code,Sectionu532hrf? �` 09 ' F-TNf1L_ OT,AL&
oyes ��F All roofs shall be inspectMiRior th 3 �holLodin in ,let.
Will the applicant or future building occupant use ey'dpicm or device.which 11'a roof is installed withoi3q.Rrst-ohtljilift 5A Id'et 'ree re
rl lwrardous air vacant an(,u,ricfne the stay Area Air Vuallly Management
�.uie[' all new materials for inspection. Applicant u stage dnd ill core I th
Dye., all non-point source regulations. PP JNIV 3 1 20017
1 have read the harnnluu.npatniuls retulr9nen11 under Chapter 6.9.5 of the
Call... is[Icahn R S.db,,Coale.Sections 25505.25W and 25534.1 understand that
if the building docs not currcndy have a mearat.dut it i.n y re,rymsibility'a nosily We
Geu r of the r iwminy-Iohich tonal tie sect Prior In o-n le at a C file of
Pa Y. IT/e{/-st
' Signature of Applicant
owwvvn ed.,cut 1 ase All roof coverings to be Class `B" or better
OFFICE