00100033 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
OWNER'S NAME: WOODrARK WYAPPLICAfI(IN SI 1 A'I? w
ONE
G z a ARC111'TF.CTIENGINF:IiH:
BUILDING PERMIT INFO
.00 BLDG r:Lr:Cf PLUMB A11iC11
N (_I - I-1 I_J
y j LICENSED CONTRACTOR'S DECLARAI'[ON Job Description
Z I hereby adirnt that am IicancN undrr pmvinioux of Chup,cr9 fm.nme ling
Fy�� withSon on7000)"I'Divicin..3ol In,Bueinese it I Pmlenxionx Cude,undnry license
ce Lin all linerandel is
ice.. Class_ Lic.N �j�S
centme_nn� 1 7 RUN ELECTRICAL OUTLET FOR GARAGE DOOR
s 3 a vii Agent rCCr'S DECLARATION
=O 5 1 understand my plan-hall h used as public¢cords
ceeST
u i p O Licensed Rofc-siunul
c u o Oad I m.BUILDER DECLARATION -
1 hereby a(Sort,hat 1 ton esmpt fmn,the Contractor',Licence Law for the
luud,r reason (3.dinn OI DIS.Bun and.. d.. +n Gale:Any cry au, ,
2�D 'hist 1 P I I p I"I I' ) -"Uam
pj� lint l I. d Ito It II ,I,u L (Ch nen
a. n+stn thaw.Pursuantl th p a-an of L+tI.Ott rsl 1 (cn,nler9 Sq. Ft. Floor Area Valuation
(comnsenemg with Secuon 91)(h11 of Division?Ofthe liwines anA Pmte,I e 'Code)
.,,but he Is exempt thmetrant and the hu-i-fit,,he alleged emorplion.Any violation
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of on ohne than eve hundred dollars MIR). - . A PN Number Occupancy TyAl
❑I.as ewncr of the pmptany.or my employee-with wage..as their sale cnmpacmiun.
will do the work,and the%mm um is not intended or altered far tale(See TW. -'
Business and Pmfes-inns Gde'De Contractor's Licenm Law,dtec not apply to ua Ired Inspections
ewncr of pmperry Who huilds or in+proves thereon,and who does such work hie+-ell
rzoIII Is h+,awn employ...,prwllecithin Inch in+pu v and are net intended n
lmred ler sale. l:nawrvat.me building m lntpmtmalla i„Inod will.sae rrar of 304. — ROUGH ELECTRICAL
nnpleliun.the tomer-builder will hate the burden Of no,ing than he did net hard nr
improve forpmDne of..dal. 501 FINAL ELECTRICAL ENERGY
O Las ewncr of the propeny,ma exclu,ively con,mating with licenced contractors to 505 — FINAL ELECTRICAL
consumer the prujnn(See,7(94,Business and Profession-Crde:)The Contmctor-
License Ww it and apply m m at,of property who huilds or improve,,hereon.
and who contracts for such pmjecu with a commetar(s)licensed pursuant to the
Cnnlrecmr'n License I.aw.
❑I n I exempt under Scc. .B k I'C fnr this Tensa
Owner Dme
W,l12KER'S COMPENSATION DECLARA'I'[(IN
1 herchy Blinn under penrhy of perjury one rel the Inllowing dmlum,inm: - /O
1 have and will maintain a C.nilicme of Consent to%elf insure for Worker', /
:ompen tar ac provide] for by Setian..... of rite Lu6n Code, for the
pcafnrmance of the work de x hich this permit is 70[) o
❑1 have and will muinmin Wnrkar's Ganpen-alien hdumnce,u-berated by Section
37110 of the Labs Coda lar the performance of the work for which this permit is IJP
,sued.III,Worker,Cnmpencmiun Insurance camel and pull”nmnhrr arc:
Carrier Panay No.. - -
CERI'IFICGII(IN Op EXEMPTION FROM WORKERS'
C(MIIIHNSATION INSURANCE
(This.mulinn aced not be camplcmd it fix memoir is for one hundred dollars
($I f(p)or less]
1 c<nify that in the petbormance of the x k for which this permit is issued,1
,hull not cmPloy any person in any ton tar c an la heaotn whject or the Workers _
Cempenna >
Not16nr .
N(Y....c TO 'I'1. 'A of Labor ion•you
oushould
hc-nmumbjrcuuthe sum An"euC+unpcn, ton prolui Shall lite Cahn Gdokud own,
p � immwim ratnply win earn pnwiamn m his,,coni,sent be d.amw rxwakea.
Z V]
CONS'IRUCI'[ON LENDING AGENCY
> I hereby affirm that them is a construction lending agency for the performance
of the work for which this permit its issued(See.3091 Ci,C.)
Q Leasee",Name
D Z Lender',Addmsa
U I cre"by that I have mad this implication and an,that the abnsc infammtion i-
4. (•" snrrem.I agree In comely will,all it,and nmn1,mdinmm,and Imre lawn relining .
1..)
11,batildirg C01111111111111,lualI by'anourim repor—andivs, I Ilul lilyt enter up("'
fy) the h I' ed ,,111,1 a 1 t P I
IW,agree I Ue.....ilyandkeep l I ss lis,City of Cupertino agt ret
tr rn liabilities,judgments, l anti ex,,laws which may III any way accrom against cad r (�
t.7 Z Cit)In consequence of theg t ag of this pc t.
APPLICANT UNDERSTANDS AND WILL MPLY iALLNON-POINT Issued by: Date
SOI :REGULATIONS.
Signmmm.f A,diranUCuntactor — a Re-roofs
HAZARDOUS MATERIALS DISCLOSUR.
Will the apNicam nr future building«alum atom or h:ntdlc hvaal".,materiel Type of Roof
un defined by the Cuptanlnn Municipal Cada nd[huller 912,athe Health and Sntc y
Code, Sectio 25532x0? ❑No
AlFroofs shall be inspected prior to any roofing material being installed.
Will the applicant or ovum building Occupant me equipment or device.which If a roof is installed without fust obtaining an inspection, I agree to remove
call hamrdous air contaminants as defined by the Huy Area Air Quality Management
� ivrict? ,
all new materials for inspection. Applicant understands and will comply with
❑Yc, 0 N all non-point source regulations.
1 hale read the hamNaus manurial,"aircma,.under Chadt,6.95 of the ,
Colifumia Health A Safety Cade,Stations 25505,25533 and 25534.1 understand,hm
if the building does not currently have a moral,that it is my re,no hill,to notify the
cupant of the c,cuncnmmm
s which mos,be one,prior In issuance ol'o Ccnitiatc It
0......buy. Signature of Applicant Date
Owner Or authorimd ago, Dme All roof coverings to be Class"I3" or better