00120156 -'JeITY OF CUPERTINO - "- - -" -- - •'�' "
ntm,umc DIVISION PERMIT CONTRACTOR INFORMATION::
BUILDING ADDRESS: — PERMIT NO3@354 14YENEWl'" . -
IS'i md),Tim [.o:::l3Th:RS `IhIC: 00I 07.C:if:',
OWNER'S NAME t .w' APPLICATION SUB DATE
-. ,! .r -hl(AlIC)h IL AVIS :I.2/f.8/c"5F(a@
'-l�•PHONE:. SANITARY NO. `" CONTROL NO.
M-O ARCHITECT/ENGINEER'. - • BUILDING PERMIT INFO..
m❑ _ •, - BLDG ELECT PLUMB MECH
II t y Z " LICENSED CONTRACTORS DFCI ARAf10N t Job Description
I thereby Ir mut I 1' a,d d p f Chapter)(' m
tc ' g - _ +
� � � wthS I 7000) fD :'on Sof lire Bu ndP 1 .' :CJ 1 yla, 'e ' ..
sinfllY and ! I'„
40< tae Class a RET1...ACE. 4(d GAI J_Obl WATER 1•JlEnTElk.
.3 w y Date - . . "
O - MICHI ILC'1"S.DICIARAI ION
C I-` , 1 understand Joy plans shall be used as Public records
se
OO 'Lie d Pool...inual -
OWNER-BUILDER DECLARATION
e '�
I henclayfl that no fronin the Contractor's License Law For the
C a
febrosirtj sectent sect7031..5,Bursirac,,and Pocnic,sma,Code An,c ry druent, " p
' f ❑ which o,quiersO peroutt .t ,Riftel,i p dedlish,Or repair any:I-pure
prV
r t t I. G ' epu PPI It M1p fl y 'A:rt�mem - b . .
mmn In : n top .on nh Conn.,...L I (Chapter9 Sq. FL�FIobr.Area Valuation
E mmcne,gwth Section 7000)of Division3 of the Busnc,. dPolus.ons Code) - ,
or that he is cxe,npl thercfn,m and the basis for the alleged Cxempdon.Any violation
of Secdon 70315 by any applicant for a permit subjects the applicant to u Civil penally _
ofIno,marc had Eye hundred dollar,($500). -APN Number ` Occupancy,Type
property,Oran,
eicrxwinitworearie mmpenaalinn,
` • L- 1:5074
w0)d me k and he I I is a., t oneoau r I (Sec.7oa
Bus f cd TheC s uer,tie l I I p1rk han
Required4rispections•
Owner rproperty wl nu is ' p m d n d n n,xelr .
� - ' '
or through 1': red Ye .p I d that 1 p t'a I- t sued nr '� �:•> -- 'FEWI" F'LUMFiIbri E br-M.•tY '
offered r sale.If,hexa er the tw 18inb p ave Heal is sold within one yea-or _ '
e ourction,the owner-builder will have dm burden of proving that be did sol build or �' - !" `er' -°
'top rpm r I ) 5QT 7 Gf-l.o 1...-f
❑I fn p pelr'Intexclusivelycontracting 0)I . d contractors I :`�!1'% -- FJ:hIF~I-„ I='I UPIL3.1:NLi '
Lon I u t
the pj t(Sce.7044 B d Pr f Cod,:)Th C t I - ��
Le L d t p11yt o,owner IpnpelYwh builds p thereof, �
I _
and sc cl [ such pm]ects wth Iraetor(s) e dp illi Ili -
Cnm m r'L'e l.d
❑I a npl carer Se ,B&PCT Ihis'r .e • ,
t I7�1
Ow Dale .. `���
r,WORKERS COMPENSATION I)I:CLARATION' - c,
or
” Ihemhy uffrn oder pen rty of ajt ry onq rfthc loll wing dcdurnl a. - " S' , ,
Cl L,have and will maintain a Cerlificme of on In ,elf-Inser,ft,Worker's'
Compensation, as prwided lot by Section 3700 of the Labor Code,'fon the tv
performance of the work for which Ods permh is Issued. -
'c.
1:11 have
d will riot ' W lo .0 np :IunlinedbyS Cm
3700 of the Labor Coke,for the p,,Iooa c of the work for which din,pe,our
ix sed.My Worker's Cnmpen,alinn Imumnce easier and Policy nwnher ore: a• q� a. ' -
Card et: Policy No
CERT'IPICATION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE y' ' •_
(Th'. section need on be conpbed it thepanni,lx for one hundred dollar's
I Comfy thus in the performance of the work for which His anter Is i"ued.I ,a -
shall col ernploy any person in any mann r.so as to bccmne subject to the Workers ~i
Con p f Laws of Calif r,ar Date
Applicant' . . , A
NOTICE TO APPLICAN P If, ft uk' gth Certificate fh pf you should "
bee n
c euhlubw thcW k t C p 'I p of lh I h C I ) Host
Q 0 forthwith eomplr with such provisions or pem'1-shall be decanted mucked. .S n3• r
Z W - CONSTRUCT ION LENDING AGENCY �_• t. -
� � ' 1 h'eby dfiim thind :Incicnlending agency for the pertrrmanee -
Gufdeu krrwhieh this unit s sa ed(Soe.3097.Civ.Cd ' n -
Leader'sName - - - ,
.7. z Lenad ,Address
U0
Icertify that 1h ad this applechot and that the M1 t, f of , - -
W Fy cn rest.1 pne, curably plY Ili ill city and county Ordinances and,latelaws relating
C.7
at birldang co I Y d hereby atnh4do,sity to conernean
r� the al f damp IY f,),aspectionp p a 'I
C6 - (We)agree to G,s,indennuffyoudk ,,hanorhosgueCIY.fCpn' again 1.
Vi liubil f . j dg u: c I I p ::which may in any wayaccrue aga st said r •• ..
U Cil,to .nv,R,r,c of the printing of this pcm.... ' - -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTt. _
SOURCE REGULATIONS. Issued by:' Date '
Signature of ApplicamUConlracmr r - _ Ilnle Re-roofs - -
HAZARDOUS MATERIALS DISCLOSURE
W'pth ,Pl wtI or hound,antitank oecaLinaacrcit,handle h,vardousm.tcr'al _ Type of Roof
',Code,
l Sred erby he Ca,0cui) M _ pal Code Chapter,9.12,and the Health lth and Solely y - - - -
17Yes - o No - All roofs shall be inspected prior to any roofing material being.Igstalled.
winthe applicantorRaw building Occupant use equipmomord....so'whilli If a roof is installed-without first obtaining'm inspection, I agree to remove
curn bro,.accou aretrationinant, 1eftedbyth Bay Arco Air Quality M agmen,
. Distrct all new,materials for inspection. Applicant understands and will comply with
El Yes ON. all non-point source regulations. i
t
1 base tod de,ha I...antrouti,
oo t,under Chple-6.95ofthe .. - ''- _ _ • 7
California Health&Safely Code,Sise on,25505 25533 and 25534 1 understand Ilial -
Flo,buildingJ .snot Currentlyhare o tenant,that it':toyrcl bilfty to notifythe _ •.
occupant of lhaeroquircdwrs which b n I prior to ixs a,a nl o Cerhfieme of '_a• - '' --
Ck6u .. '
panes. . —Si gnature of Applicant, `Date <
57-er-1 anntod,Pdagent .I ..Date.' ;_`, _ r All roof coverings to be Class"'B':or better', ,
OFFICEt:. t _