01050207CITY.OF CUPERTINO '
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INFOWNT,
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emt.mrcntvistoN, PERMIT.
CONTRACTOR ION..7
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EUILDINGADDRESS. -
PERMIT NO. •. i{
ZA BLVD
LEWIS .AND TTBHIT'1"S.
INC. $10502^07-'-- <,
OWNER'S NAME: ✓
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APPLICATION SUR DATE
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SANITARY NO. CONTROL NO.
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, _910165703 31
4 ARCHITECT/I NGINEER:, ', yo.
t - - BUILDING PERMIT INFO
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BLDG ELECT . PLUME MECH
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LICENSED CONTRACTORS DECLARAI ION.'
,lob Description
1 thereby affino that loan licensed under Pensioners 0 Cimidar 9braveng
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1, Station 7001EolDivision 3 tiffla, Business I dProfession, Codeandruyl
bi fuldclm, 'a rr«t CSA Zg��¢/o_�
'a L
'200 AMP. CEVs• ,
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y Ote�rSDCLARATID
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"FINALE'
I understand my plans shall be used as mobile record,
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JUN 7
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Licensed P .s
l.'nul OWNLR ROILDCR DECLARATION
or I hereby alEnn Nat 1 am exempt from the Cmhowbr*s License Low for the
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< following reason. station 70315, Runiners and Professions Code. Any city or county
❑ which rcyuirm a permit ter conetruet, alter, improve, demolish, or repair my ah'meture
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se prirrur Its issuance, 1.1111 requires the applicant for ouch mean,10 file v signed astronaut
- rein :re, do u m p nn Coal t License la kenpmr9
'Sq.Ft. Floor tea Valuations -
(,.arm...g fns Y 71100) fD' 3 re, 6 aJP r:: ce9
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or men be is exempt therefrom and dm basis for the alleged npuen Any violation
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of Secb°n ]OJIS by uny appllcam for a pu'mit sunjnm, the opphcvm m u civil penalty
of not more (from five hundred dollar, ISSUE. - " -'
APN Number
'Occupancy Type '
ot
3
woIdowner°fineprthevmmye is
roeedfor sale ec.,70oa,
will ng the wink and the ode The is not intended er offered for ,not apply toad,
intended or
Basinger. and Code. The Conbnemro Luw dws not apply m roup
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Required Inspections
owner property Who builds
ow fp p ty Nit 'p m and 1 cities . 1 Mhtnselr
, and w
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r through gh l ply s p ded that .It tentative r of r , imported nr
304.. • ROUGWEL:ECTRI CAL
offered lot sale, It, however, the b1.ld ng or imp met I I ith me year of
complut11mthe owner builder will have mehandenotproving that hed'gnot holdor
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'g0I — FiNAl ELECTRICAL: ENERGY .
impeoef11r pamnseorisi
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505 FINAL ELECTRICAL-rs,?
• E] 1. r the proper,,. ,a exanivi,vly cornmeal, wiahl :ed arritneelve,to
, ad Probes Code:) the Cour arm',
n. we, the project (See 9144, Errs ae o
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Lt.enxc Law does ren apply to an owner of pmputy who builds (a, impn,ves thereof,.
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and no mumbla,for such Incroac with a'cnnbaclums) locerbed.phosmant to the
Cot urs License law.
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❑ 1 nm exempt under Sec, , R & P C for this reason
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Owner Date's n '
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" WORKER'S COMP@NSA'rION DECLARATION
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IhcreM1y mfinn under pnn1.11y of perjury ane yrthe following dwWratiors:
❑ I have and will maintain a Certificat. of Consent to self-hsure for Worker's
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Cempensatien, as provided far by Section 3700 of the Liii, Come, for me-
performanceof me work for which this per?,m to i,eueJ.
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1hI II instant,, 1aaydhy9t
37Wfm Labor C I f d-f
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_ p or the work h hth`pe t v
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_ is' t.,MyWorkers Compensation fin,brance arrer andP l
beper me.
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Carrier Palley No �� �4�d6
CERTI�EXEMPTION FIFO O Lhi�V id >Rk S'
COMPENSATION INSURANCE
'(Phis section wad not be completed 11'the emit is forme hundreddollars
fS 100) or lass) r -
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1 send ry that in the performance of the work for which this pormit is Iwmmd,`I-
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shall not employ any person In any awnrer vo as to become subject to the Workers'_
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Compensation Laws of California.Dam
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-APPlicant
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NOTICE TO APPLICANT': IL after making it... Cenllieme of Exemption, you should
become Inducer m the W6&,'e Grmpena o on pmvisians of the Labor Code, you must
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buinvi0r comply with such provisions or this permit shall be deemed revoked.
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' .. CONSTRUCTION LIP,DING AGENCY
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I hereby affirm that there is it construction loading agency for the perfdrmaace
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'ifthe work for which this permit is Issued (Sec 3097, Civ. C,) -
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a Lender's Name
Lcndcr'IAddresx
I testify that I have read this applioainn and Stam Out theabove information is
avorman. 1 .gree mcamply.wlot all city and county endurances and state laws relating
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to building construction. unit hi authorize representatives of oris city to enter upon
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j he aM1ovo-nmmlorcd pmpeny'fnr inspection prCow,,
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(We)agmetscavo, kehih
Cityef Cupmiaoed
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liabilities'andexpensesmayinthe
said
alilin . fragments, a and xpe h h may r any y said
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.against
" City in consequence 1 m goodng of h. pe .i t.
x APPLICANT END ERSTANDS Aye ILL C PLY WITH ALL NON-POINT
SOURCE REC ILA 0 i// ' r/
Issued by: ��' . .DBIe
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sigyul rApplre nr/t77�r��r'//
Re-roofs
(� Air LARDOU.ti MATERIALS DISCI OSURF'
Will the applicant future building pant store or ht dl h d r1., mmenal
Type of Roof, -
as defined by the Gunnel M ipud Cade Chapter 9,12, std the Health and Safety
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Cede, Seednn 2553drC -
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All roofs shall be inspected prior to any roofing material being ipstalled'. ,
Will me appraoro m fitm�e mrildingeaatpntd u,. eympment nr'd.vmnx wldbn
If a roof is without first obtaining an inspection, I agree to remove'
emit hascub.s air wntaminant, as defmed by the Ray Arco Air Quality Ma recent at
Dhbkt^ :, `
_installed
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all new materials for inspection. Applicant understands and will comply with.
71 Yes ' .}' "°
all"non-point`source regulations..
1 hr ve red the hazardous material: requirements under Chapt r 695 of theCold.,n
n t{ealth & Safety Code Sector 25505 25533 and 25534 1 turnaround that
If the I... title does not currently h1.ve tenant, that n is my aspbnsibiluy n5 notify the,
nccupum bf he requirements whit nst be mat prior m ivxuunm of a Cenifenm el'
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'Signature of Applicant' - _ r -• � Date. '
All roof coveringsto be Class "B" or better
ra.I bred a ate,
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'' .'• - - OFFICE ..