00170194CITY OF CUPERTINO
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INEORM'�ATION
BUILDING
PERMIT
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BUILDINGADDRESS: ,. � ,,
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PERMIT NO.
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OWNERS N/IM1�ji E6'CICILBY AV-
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APPLICATI
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ONE .IC1SH VARSHA -
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SANITARY -r O -
ARCHITECT/ENGINEER: - s
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- v ` BUILDING PERMIT INFO
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BLDG;. ELECT. PLUMB. MECH
LICENSED CONTRACTORS DECLARATION
Job Description '
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Ih ly fl lhtl 1 W p IChapter 9(connc g
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(hS 1 9000) rnrmeIT r a ry)P ; h fi
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REF'hPE WATER HEATER- & WATER MAIN
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jLwa... d Pm@ssion,l,
OWNER -BUILDER DECLARATION
•1 hereby affirm (hal 1 anli
i exempt mn We Contractor's License Law for fire
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y following neuron. (Sermon 7031 s, Business and Professions Code: Airy city., county
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] °which requires a penult,, com¢n b, alma improve, demolish, or repair any.v(rmcmre'-
prior to els issuance, also requines the applicant for such permit t(;Wc a signed statement
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Valuation
'bar he i, licensed purtub thepowkowncofflne Coal ... lineL<: 1Uw, (Cnark,9
(co Ic..nog ME Section 700() fIncii 3 fd Basanc untPr rc�I <us Code)
or that he is exempt therefinm and the ha'sis for the alleged extraction An, violation,
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of Section 703 L5 by any upplmmn for a permit whyer,'be appliance m a civil penalty-
.raot more than Bve hundred dollar, (55001. -
APN Number
- 'Occupancy Type' '
oper stn .'I p :f
DI of he P]thes r ply
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�- 21200,
Bwillus d thek i the o t � t intended B d 1 I (See. 70.Y1
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Business I I- f code Th C t t C 1 d 1 apply (
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( Required Inspections'
froor f property Who builds or iniproveIthereon, and who doessuch work himself
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m'bmtgh nisoxn provided that stch oldas not intendedor-:31628033.
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however,
" offered for sale. If, hnEeold,e building or elcneI,
einem o sold within
not year of
burden
completion, the owneebuider will have the burden of pmvin6 ehnl he did not build or
d
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improve rnr pa,pmse ar.aie,)'
502 — FINAL PLUMBING'"ENE,RGY
CI rofthepre'ro con,"I, ( e wifir licensed coubso or
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ca 7044 B
506i— GFIS TEST - - -
m e t th pro,. (S I Prof Code ) Th C e t :r's
License L d. 't pply I f P p ty M1 boll p - thereon
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507 = FINAL_ PLUMBING
,ad n .ttaatafn altpnnJetirrtan cormm.a,) sedpin.,an(m.n,q
Connhrors License Luw. 4 a
❑l amcxemp ccallo See ,B.@PC for this rca,nn.
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Owner Dan,!
t WORKCR S COMPON DCCLARAT ION
Ihereby affirin underpenalty ofMJ > one ofth billowing iI
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7Ihaved will uninitain a Certificate ofConcert t h for Action's
2oloptiontion, us provided f by Section 3700 of the Labor Core, f [lie
,onforicance ofthework for 'h h thic peranit'. d
❑ l inaintrin Worker's I nourance, a,�bo,iircd t
y Section
s.
,Counintation
.b
00 of the Labor Lidr p rl d k (hconch is
owed My WYkersC p_a[I un reand Policymmbe are
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C� �have
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CERIFICAONP( EXEMITION initial WORKERS'
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COMSATION INSURANCE
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(This rection need ani he reordered if the permit is for one hundred dollars
(310)orlcsx) -
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Icertify that in the performance of die k Pruthichttis Protonic a.sued,l
shall not anplay any paned in any mann .o vs m Inaction sublet (o the Workers'
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Computrrion Laws of California. Dam ..
Applicant
NOTICE TO APPLICANT JL nOrs roofing this Ceadwitle of P.ncmpt er, you should
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hwama suhject to the Worker'n Cmnpensmlon provisinnx nfthe Lnh.r Code, Y.0 ams`
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'e. forth b wmply withsuchprovisions is, Penni, shall be decrial rev.ked.
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CONS'fRUCI'IONLENDINGAGENCY
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hereby omnn hal there is a construction lending agency for the perlonnance
of the work for which this permit Is ismac l (So, 3097, Civ. C.) ..
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Leader's Nuns
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Leader's Address
I eerily that lh - -ad this ,thetifitnernalfine Wat'ba ab- finis in
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n acts I a sec m cam with all cit and count onnornws'add mate law, relaun
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do-accotonodogand
n officetitatives of chis drymenmr neon
,heto
the above ane atoned ....... ly r spec(i offices.
i lyI inspection
(W) S I d ph 1.. the Cite acpt' 6'ts
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pensee
( tAdBncnx,c ( - I expenseswhichnoy'n anywY accrue
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City
City ina:naal,er�nnne 6rnnting.nnia recruit.
APPLICANT UNDERSTANDS AND WILL COMPLYWITHALL NON.POINT
REGULATIONS.
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issued by:' Date
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SOURCE
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Sign a tor° of nppreant/C.nnanor - ..Dmc,
Re -roofs
HAZARDOUS MATERIALS DISCLOSURE
-• Will the applieane or fumyn building occupant store or handle h,zardous maaial'Type
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of Roof'
as defincel by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
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Code, Sort 125532(.)'! ^
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❑Yes '-' El No - is !
;All roofs shall be inspected prior to any roofing material being installed. �i
wi11tnatppricamd,futurebandiagnrcapantif nof,pmemnraevicer'wnicA
AIf a roof is m4idled.without first obtaining an inspection, I agree to. J"
emit hnzandrLs air comaminana as defined by he Ray Are, Air Quulily Manugamcnt
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remove .
all new materials for inspection: 'Applicant understands and will comply with
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'all non-point'sourceregulations. -• - -
1 have read the nuzad.as mufedat, nondocmenn under Chapter 6.95 of the
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Call( ..i,Henhh&SefetyCnIt, Secei.ns25505,25533and 25534. 1 i demand that
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it bandana 'd pr (IYh ,tea t (hit r'. Yrc p .blllyt burly the
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oce, I,It- ( "1 nusLh (p Mr
a. is,lc Cndita(eof
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Signature of Applicants; Date
37"'Cl
,(' All roof coverings to be Class "B" or better
own', or Oillnuaedug r ,Date
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OFFICE ;,.;r,
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