00100032 OF
CITY ILDING DPV(RONNO CONTRACTOR INFORMATION:
PERMIT
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: " APPLICATION SUN DATE
24117195 GRENOLA DRIVE CUPERTI:NO CONSTRI.JCT .ON INC00100032
ONE. - .SASE I'ARY NO, CONTROL NO.
—CHUNG' 1.0079 SAICH Y0/104/21000
G K Z ARCHITECT/F:NGINF:ER: - BUILDING I ERMIT INFOdo - -
uFIOO BLDG
ELECT PLUMB MECH
z (408) 253-9000 o u 1=1
I yQy
III y Z LICENSED CONTRACTOR'S DECLARATION
I ���o nfe nr'nimf that l anf firecirsed orderpmon,mar,ofen pt 9(coif none ftg : Job Description
Hw wllS i ]fAln) fD' i Tth E ani Pr f." n CW•and my Tcense
< -f Lovcr 111 f rce anJ ell pLQ
C zit Lic neCl 1 p � Q-!
e'0 1- Dore f c f f !�/, _ . .
<17
RCIII rFCT SULCI ARAI -- ��/.
ae°"g dcry pl,t,xnallbearea I brereetmx' TEMP ELECT /O!
car
is=p Licensed Pt. ional
OWNER-BUILDER DECLARATION
1 overlay action thin 11. eBusin f fit Contractor's L' Law far the '
r,ZQ whobillowing (Sufon 9031oict.ae JP [ :ionsCdoyeity or county
as o
which require,n permit in amsfine(,ober,improve:demolish,or repair my strumure V
ea prior , issuance,alsoq Yesthapplicantf hoe til fl b dsmte nem '
Ilia he licensed a...ato the president, Title Coal...... License Lou,(Chapmr9 - Sq. Ft. FloorArea Valuation '
(d In" g ithSec( 9000) fDivision3 1it,E .`w IP f:.ons Code)
or that he is exempt therefrom rid the basis ratio alleged exemption.Any violation
of Section 7031.5 m myupplleant for riwroml chice.the applicam to n civil reality
of not more than eve hundred dollar,(5500). APN Number -• Occupancy Type
'
El 1.as owner of the property,or my employees with wageses their sole compensation, '
will do the wort„and the structure Is not'intended or offered for sale(See.9044,
Businrss and Profession%Coale The Contractor's License Law does not apply to an ' Required Inspections
w raf pperfv Who builds or imdmmcon,vos thno who does such wad Herselfor avm
aagh his awn empmyee%_provided Inco such improvements are nor intended or -' 326213609. 00 .
offered for sine.IL however.The building br improvement is sold within one year of -
completion,the owner-huildef will leave(be burden of poring that he did oat build or "
improve for pufpose of suleJ. , -
❑1.axuwaerof the property,ame.ewxively, contracting with licensed contractors 304' — ROUGH ELECTRICAL
construct the project(see.7044,Rusinesv and Professions Cade:)The Contractor's 501 FINAL ELECTRI CAL' ENERGY
License Law does not apply to an owner of pa,cny who mihL or nuances(hereon, ,
and who contracts ler xach mites with a contractors) licensed prearom to the 5@5''— F I NAL ELECTRICAL
Cormilms License Law,
❑I an exetnptander So,. ,E&PCfor this reason
Owner Uric
WORKER'S COMPENSATION DECLARATION
I hereby affirm muter penalty of perjury one of the fellow'mg declu mations.
�O 1 have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation, its provided for by Section 3900 01'the Labor Code, in, the _ -
perf nner..e of the work far which this permit is issued - -711 have and will terraria Worker's Compensation Insurance,lis retrained by Smtinn '
3701 of the Labor Code,1'or the performanca of the work for which this permit is
,.sued.Myy WWo✓kzma C/oouperensafionn Insurance earlier and Policy number are
areof
er
.
Polic
CERfIF'ICAfI' OX4IF EXEMPTION RO IWORKis' '
COMPENSATION INSURANCE
(This sectionneed not be pr tut 11 tile p i;is[ hundred d llars -
idly but in the performance or he work I., I' hin,Noun visioned,l 1
shill n t employ any dere,1 in any farmer f as to,b,.cre subject to the Workers
Com mucron Laws of Califeraic.Date ..
I'Applimiant
NOTICEAPT If, fter making this Certificate ofoptonin.borisc
zbecome uncof
ollusW k C p - 1d :ofthc Labor Cyou nmt
mohicomply with steh pmtclear,nrh s demi t inti be deemalinv.k,d.
'
4CONSTRUCT ION LENDING AGENCY
a I hereby affirm that there is a construction lending agency for the perfornnrce ,
F37 of he work far which this petnif Is Issued(Sec.3097,Cie.Cr -
Lender's Name
z Lender's Addrca' is
U
P II ote1.camvc ithoithis ity ad application and ontefhmtheda uta law,mini +
W tofmct.I r rzm or carm,with al)cot ala count orhmmas aW state laws rebates
0 V -the aboingcomoned himby affhlx city to eater neon -
C6 'the ahn(We).,a ,,rmreny for inspection and keep
purrosex.
F cA ll,'un nee m xavc,In.atvfify and who h mayi%the wayity r cite w,o d said t
r 0 City ides,sequence i eons vnJ expe this
which may in troy way accrue again%t said
City in consequence o11he g of this permit
APPLICANT UNDERST NOWILL COMPLY WITH ALL NON-PO- T IssUedb - Date
SOURCE REGU / (✓ _ Y• t
✓` I
S, �fere mar maw AeAR eI me Re-roofs
HAZARDOUS MAT 1 .5 DISCLOSURE
Will the applicant or future build' apam store or handle m7ardoes materiae Type of Roof
as defined by the Cupertino Munidpnl Chapter 9.12,and the Health and Safety ,
Code,Scetion 25532(0)^.
Elver ❑Nn - All roofs shall be inspected prior to any roofing material being installed. ,
will the appliem c'frocebuilinginceupam egmev}res
axe pmetdnodwhich -If a.roof"is installed without first obtaining an inspection, 1 agree to remove
coif hrrurmns air anlammurts as defined by the Be,Area Air Qualify Maougcmenf P g '
>ixfaer� all new materials for inspection. Applicant understands and will comply with
avec ❑Na all non-point source regulations. -
I have rend the hemrdous nationals raqulrenmnts under Chapter 695 of the -California Health&Safety Code,Sections 25505,25533 and 25534.1 undersand that
io in ingdo s notcurecalhavcafenan6lhat it is my rcnpousihilify of notify the
empmt of tit mareas which,most be no,prior m issunn- f a Certificate of _
�/ Signature of Applicant - Date
( ndnrredg /—'7-'-D�� All roof coverings to be Class •`B"or better
e