01010115 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS; , PERMIT N(I. '
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OWNER'S N Mli: 90/ O'-'^ APPIJCATION SUR DA'I'li
II WSHE ,`?6) 76 �3 ) n'. ,5 �� SANITARY NO, CONTROL NO. .
O O ARCHITFCnENGINEER: - �r//n�� _ `�. BUILDING PERMIT INFO
w C BLU I- ELECT PLUMB MF.CH
z S6F 6 LICENSED CONTRACTOR'S DIiCLARAI'ION
N z 1 neren lrrm thal 1 am Bcensd anter PChapter 9 hem„tneneing Job or
oz—Q ya pmvisinnxn,
p LBF; with Seninn]010)of Divixi� Sof the l{uslnese and i'n,femlOns Codemajoeylissew
x ,m mu Baca n n erca�3e� -7
z a Linen+`c I Lic.a
i5 3 a s- Dme v'J d-Z Contractor '
ARCHITECT'S DECLARATION
poO -I mWersnmd my plans shall he used as public recool.s
6 p p IJcenseJ Pndkssianal
R 6D OIDILDER RATI ONi1— I hereby fdlJL Iam pt from the Contractor
License w for
b 15 Y 7131 5 If nJ I CodeY ly cawrywhi hrcyu 'remit oconstruct,ulter, p demolish:
ep y mere
pols issuance.also requiresthe applicant for-chpe a
,°• — ,nf ) signed statement
olicensedp rs u , provisions of the Centeno Iis 1 (CM1agerY
Sq.-
AI. Floor-Area, V81Uatlof(cmmen with
thgh ]U(NPel Uvson lee Business and prof Code)
sal e. npr theirf I u11photo Any viPny
vu ]IDISbYUY rItaparmi,subjects
uhl ts[lie applunlwacivil r<nahr
.ant Ir Rrehundreddollars aseAPN Number OccupancyType
+
❑I,as Owner of the pntpcny,ar my employee,verb wage,as their rule cnmryn,etion,
will JO the work,and the how urc is nn iaw led nr offcl'of 1'nr tulle(Sec.7044,
Business and Profusions Code:The Cojhmclnr's License Law dues hill apply m an
'Required Inspections
owner of proryny Who builds or impmvcs thot and who d«s Ouch work himself
orBroad hs own carply provided that such imparstalichis am not intended or .'
offilred fim.oila.If,waverer,the building p n ,In will thin t year of
c.mplf n.the haddle,sellI h,hoa bardbaci win,that radial airh 'Idn
im,wwof 1 rte L I )
❑1 as- prte
pty I y m ,ng - ,
c .l I theproject(S ]144 BI. ,and l I . :C 1)TI Contractor's
h
tic t. f such project,,with u cnnmartI ed pu:u m to the
Council LicenseLa•Lice 1 due, a 01,111to an—asr Ofpr l who wild, rar,w,c,lowou
l or.airmen and"Sec. {&P C(,,,,his ream - ' • !///C/—J/ '
,
_
,
Owner 'Date • -
WORKER'S COMPENSATION DECLARA'HON
• I hereby often under l malty of perjuryone.(,he following dculnrufinnc
O I have and.wlll maintain a Certificate of Consent,e .ell mere far Worker's
Comryn,mion, as provided for by Section 3701 of ,he Labor Code, for the -
performance of rhe work far which this permit is issued. - -
hove and will pminwin WmkeL,Compensvlinn Inwaac,m required by Secfmn
P91111 of Iho IUMr COJO,far the perli,rn,ance of,he work far whicL Ihix permit is ,
nsucd.M�y W'n/�r/kd•.s��/.Conmpensmirnr Inwrance camie d Policy numMr are: ,
' COMPENSATION
OMPENSATIION INSURANCE
NS1RANCE
., .
This section need no,be completed it the permit i.Tai ane hundred dollars
8190)or lux,) _ ..
I certify that in the performance of the work far which In is permit is issued,1 -
shut]nal employ any person in any manner sin as to become subject or the Wmken'
Comrynsmiun Laws of Cul hrum ]late f,
Apel imml , - -
NKA'ICE Tj,"M'he AN Worker
:IL Ofm.i'marg they Cerwi....,of of the LamplCor you......aid
Z bachwith comply with
ConryOreton peroot shall rbc LuMd mock roe matt
O C n,nnwitn comply wan seen praaidnr,x Or air parmh,han be deemed re,akea.
Z
(~ C(1NSereis a'IDN LENDING AGENCY -
' I hereby afMh leis perm t iit construction lending C C.) for perliamontt :
W of the work lin which his permit it is,ueJ(Sec.3119],Civ.C.1
Lender's Name
z lenders AdJr,•.,.,
V 1 emery that I have read this Opplicaticr and s,.,a[his the above information rrIs -
coect.I agree,o comply wed,all city and county Ordinances and sate laws relating - -
0 f, tobuilding con.amnion,and hereby authorize representative,of this city to cmerupon ..
r� the ahovemwmionrd pmpuny fm imspcetihn pue,ose,,
(We)spree M-Lava md....ily Ona keep hannle.cv,the City Of Cupenino.gaunt
Z1 l ihbilides.judgmems,coos and expenses which may in any way accrne against said
4.1 City in umxe9ucncc move granting of,his permit.
APPLICANT UNDERSTA'l5 ILL COMP Y WITH ALL NON `OI
sOukcE REcuLAvo i� 0I Issued by: �`e. Date,
Signature of APPlicant/Contmnor Dula Re-roofs '
HAZARDOUS h ATERIALS DISCLOSURE
Will lncaMliclm(or foram wadingoccuhanrslow mhandlehazardous numeral Type of Roof
ro defined by the Cupertino Municipal Coda Ch:gncr 9.12,:Wal,hc Ilcuhh.nal Safely
Cola,Semon 255331,0^'
DYef
All roofs shall be inspected prior to any roofing material being installed:
Will Jac applicant or future bidding occapunr use eynipmem m de,wes whioh If a roof is installed without first obtaining an inspection, I agree to remove
• enii,I;. ]nue wreomaninums as defined by[lie day Area Air Quality Mnnagen,ent -
ni.vinrO)c 4 all new materials for inspection. Applicant understands and will comply with .
all non-point source regulations.
I have read the acrandows asiterialsl t nd Chapter
6.95 the , .
Glif" Il uhhffiSnrryC J S a 9 x 5505 25531dn--SSW t ,dd 11 I. -
fthebuilding does not currently have weand,th, t prcap rtb'I rye ,if),hc ' If] 1 oI
lwcupan,of Pe re 7mvwhich all be mer pit or, ssu' c f afertificate of ' dNeB
ocnp ae - Signature of 4plicant Date
!' O
O ner-M,malmi-ii a oat _ - I ate - All roof coverings to be Class"B" or better
OFFICE ' .