01030030 YdgTM rCuur 11V F"UUMIMnn
CITY 11 DING DIVISIONNO
PERMIT - CONTRACTOR INFORMATION: '
BUILDING ADDRESS: � I - PERMIT N0.
T o
,y OW'Nf:R'SNM1L APPLICATION SITE DATE
� 5�9rnES 501 n 6is
PHONE: SANITARY NO, CONTROL NO.
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Roo ARCIBTIZMENelJf(IJP`90. FALL CT @m4.Q➢t'��I +I'�MED
BLDG ELECT PLUMB MECH
au
1=1 I-1 CI I=I
y z 'BNAF.bTTN RIf AES.ciLRAQND JOANNE TRUS 03/07 c 01.
z 1 herab mom that I an,licensed mnder provisions of Chapter 9 Job Description
O Z=0 y n 0 p (cnmmenense
st-tV with fallI n7mXB of Divivinn3of the Bus�u•,xs unlProfcnsiuns Cnde.and myllcensa
rcis In fall pore[= 0
z 6 License Class_ _ µLie.N_�
3 a N naecommcor�
e7 / Ao,allIes,a DF.CLARAT(.
[understand my Plans,hall be used a public reurnR 5/rv1
wr
y
atO O Licensed inner,
o nal
OWNER-BUILDER DECLARATION
1 havby llimt tha 1 am exempt bonfire Comme=nt s Liron,c law fnr,he
(=z¢ alllnwing rcmon.(root t )0715. t,alter.
and improve.
demolish,
h,or Any city or county .(
ed D which re u' s ani na mow=n,aper,int msec demolish,or repair n structure EO
� $ thin he its issuuna�•.rRan',1.Them applicant fffic an permit In tile sIsme( hapten t NEW FURNRCE07
mat he :f : lh t, th p nh C,out 1 I (chapter) S Ft. Floor Area alua[ion
(cn g afa a ]m an of e 9 fu 11 I I 1 :: ,,Code) q' / �-
nnh t l t pt th f lisp k-;f tl Il g l t t Any,inlm'nn if
of Section 71315 by any uppl'cam for a prom t,t Meets tha applicant too civil penalty
of lot:ra,mtttlist,hamtmddollars($5W). APNNumber Occupancy•IyPe
❑has ownernnhe 11111,Y.-,my em.lnyecs with wage,as meirsola, n,mmaion,
will do the work,and the s,tucmm is net intended or oBered for sale(Sec.7W4.
amine,,and Pumea,in o Coda:The Cim,memrs License Law ones am apply to as Required Inspections
owner of pro pony Who Wild,or improves thereon,and who does such wort himself
or through his own empinyces.provided that.such improvements um not intended or '
offered for sale.If,hawcver,the building or impmvemenl is sold within one year of
iompletion.than,w,-builder will base the h=ake.of proving tha he did not build or $1600
mprove for purrymc of sale.).
❑1,as owner
of prnpeny,am=elusively contracting with licensed contractors;to 36213tD08. �Q1
construct the ro ect(Sec.701 Business and Profession%Cade:)The Contractor's
License Law docs not apply to an nxner of property who builds or improves the..on,
and who contracts for such projects with a contractors)licensed putsuam to the
Contractor',Licen w Law.
L7 lam axon�ten,d/e�r See�. R a P e for this mason '"2'04 — UNDERFLOOR FRAME
ownerivu�na..�— to 3'-��'f�� 301. — ROUGH PLUMBING
woRl<I:R'scoMPErvsanoNurcLARATON - 303 — ROUGH MECHANICAL
�r Ihembynation order pendlyofperjarynummefollowing dealanninn` 304 — ROUGH ELECTRICAL
❑ 1 have.,at will mainmin a Cendlcme of conical h,self-imam Air Workers 505 — FINAL ELECTRICAL
Cnmpemmin i, rev provided for by Section 37IX1 of the Labor Code, for the
performance ofthe work to,wbirh this mnit is i„aed 507 — FINAL PLI.IMB I NG'
U I have and will maintain Worker's Compensation Insurance,as required by Section 508 — FINAL MECHANICAL
370f)or the lalan Code,for the performance of the work for which this perm,is
issued.My WWm�on'sCndominnnlnsaranse,..marrmadP/nreynambe,arc: 514 — FINRL PUBLIC WORKS
Carrier:I_I rE AIIOr� y No.: _ 61 /dP+N(>A1 N'U�RS7—
COMPENSATION
COMPENSATION INSURANCE
(ibis section need not Ise completed if the Term,is far one Imndroddollms
($1(111)of less.)
I certify that in,he lserfonnance of the work for which this peril it issued,1
- shall not employ any pets n In any manner so us m hurt...a subject b,the Worker,' - s
Cnnmcnrtninn Luws of te_ ,_a 7. /
Ap,fta
NOI'ICG'ro APPLICA TCIt.aM,making this-Cerofcam of Lxempbnn,you should
become subject,o me Workers Compemadn
nn provision.(it Labor Code,you mm,
0 Q finosith confily with such...visions or this permit shall redeemed revoked. �\
P� 14 CONSTRUCTION LENDING AGENCY
a } Ihemar affirm that mertisa construction lending agency for the performance w
ofthex,Name as Inch this Permit is issued(Sec.1(197,Ci.'.C.)
L Q Lender's Name
� Z 1<ndeLs Address
U 0 1certify that l have read this application and.ante that the aMvc information is
fi F. correct.1 agree to comply with all city and county ordinances find rune laws mining '
O G•J b building communion,and hereby au,horim rcpmvoamtives ofihi.s city..¢mer upon
} frl he ahnve nmtnioned property far impec,ion p,tow'.
�kyy ry fWc)agree to save,indemnify and keep hamdess the City of Cupcninoagainn By
f� W linhiliticv,judgments,rest,and expemes which may in any way untrue against raid )
U City in cnnrctjucacc or the gmarng of this permit ,
APPLICAN'TUNDGR.STANDS AN WILL COMPLY WITH ALL NON•POINT
SOURCI d. DNs. Issued by: .7 /�u7�&, -Ce s Date
Signal.. dAPPlic ml(.amrnc..r Date Re-roofs
IIAYARDOUS MATERIALS DISCLOSURE
Will the upphcard or furore building occupant stem in,handle hauWo et material Type of Roof
m defined by the Cupertino Municipal C e,Chapter 9.12,anti the Health and Safety
Code.Seen..25532(0!
O Yes All roofs shall be inspected prior to any roofing material being installed.
Wll,he applicant fir future building aceupam use equimnemmdevice,which If a roof is installed without first obtaining an inspection, I agree to remove
emit h M,ta aircnnamir md1.1 de,ine the Bay Arca Air Quality Management
Dior? all new materials for inspection. Applicant understands and will comply with
°yes °' all non-point source regulations.
I hoe .,it the Imcsolmts nmmrials rcquimments under Chapter 6.95 f,he
California Ileaph k Safety Cnde,Sections 25505,25533 and 25534,1 undersand that
it the Wilding docs not cummdy W,a.,maanl,that i,k my m,for sihility to maify me
mrupnn,of(be aparetncnts which must be me,prior to Issmu¢c of a Certificate of
m�pan
Signature of Applicant Date
ownermnmh!ai,en-ttgent nae _ All roof coverings to be Class "B"or better .
OFFICE