00100155 • CITY OF CUPERTINO _ PERMITNo.
BUILDING DIVISION PERMIT CONTRACTOR,INFORMATION:
I
UI'DIONG ADDRESS1,0444 TTIDRIVE
(IreTh
'YD SANITARYNO,0 VFj3WjI,Dt1R�pSU,BRM�ITfAL DATI
WT'S NAME: ) � _971
O L012_—,C CR8Ur0
CHITELTMENGINEEN HOLDING PERMIT INFO
ce
sec_
nue
F 7 LICENSED CONTRACTOR'S DECLARATION
Z=c 1 Mmby affirm tall I an licensnhnha upmvi. of Chapter 9(=ommeneing Job Description
Ino wi Smtion]000)ofDiAsion3offtBmincssaM tmiw^C^Odc.aMmylittnxis 1-&-G TO TRG
ie full form ash eRccTe, il3
w Littna ss aLic.B
5 LL H Due Connector /
R rffECfS DECLARATION
lunchroom my plugs Mall boosted a public meads
m ¢.
adoLicensed professional
u _ OWNER-BUILDER DECLARATION 'J
H Y.r I hereby M.that 1 0m eason,from the Connectors License Law for the 0
o following reason.(Sedum.703I.S,Business and Pmfeuionv Code:Any city or county
C whim ter .ther.perms l0 comwol Mer.improve,demolish,or s=tair any aw=mm S FL Floor Area � Valuatio
3� prim mils Jeannine,else rcquims the applicant fortieth permiuo File a signed mmmem q ^ 0 g-S 0 p-S 'O
Nat he is licensed pu.of to the pronilons.f Ne CounaLimns Law Limnlaw(Chapter 9 ;P
(commencing with Section 700p)or Division3 of Ne Business tial Professions Cadc)or N Numb r Occupancy
Type
thanSm he ie eamp dtemfmm and Nc bars for the reneged exemption.Any violation of `J'ZG'— ,Ri I)I t r�C.6r'C Y
Section hen by tiny.replicons fine pastil mbjaa the applicanuo o civil pmalry of e7 G.S.r'J Vr421 0
t mom Than fiveseprofhundred dolma(8300).
wi LasownakrNepsethort army. noode.withwageaNeo-(Sec.
c.com.Burns . Required Inspections
will de tr work,]she:Ilse
c ortisnen.Lima Lew dofm Weepply to an Business
w eo,wh ons tale:The contramr:IJ=enre law ane..nor.reply us if owner th 305 — FRAME
his o nY case boas,fir improve Norton.W who does such work hims.lr f thmuM
his ownemployees.provided Nasuch impm.soldwa.net inar,of re offered for 3'07 — INSULATION
aleer-bulve will haethebor impmpemenl iaaaawwme,Wilarofeumple for the 601 — ROOF TEAR OFF
mwter-wdaer seal M•c the careen or proving Nat M ata nor was a impro..raper.
pe.ewwe.). 602 — ROOF PLYWOOD NAIL
1,as owner Of sh,property,w ex=lusivrly connecting with Bernardi contracmn to
construct she project(Sm.>Osa.Buaince.and Professions Code:)The Connect&.Li- 603 — ROOF BATTENS
cense law dans net apply je t,owner mpopary wM wilds rs improves Corton,eM
who Lectsfor such prolate wiNaronuactoRr)licensed an
pursunto the Connectors 604 — ROOF IPJ—PROGRESS
License
slaw.
❑I an cxemp asses 5«. .B&P C for this rtason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby aRrm under penalty of perjury ane of the following declaratiau:
I have ash will mzrnwn a Certificate ofCcomet to elf-insue for Workers Compcn-
miou,as provide]for by Section 37M of the Labor Code,for Ne performance of the
red for which this permit is issued,
I have and will mxinain Workers Compensation Insurance,a required by Section
.lip of the labor Cale,for the performance of the.,it for which this permit is issued.
My Wos;e.rc. plm Aarrandloticy; ilt-a4-7
Cartier
Policy No.: K 1
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This reeinn modern Aecmmplend unh.ptmt in forone hundred dollar(SIM)
or less.)
1 certify IMl in dm pedo...,of de work for which this permit is issued,l shall
nen employ any From,in any manner so u m hecom.cubj.m nM, rkep C n^
ration laws of Cahlber,a Daa
Applicant !h2 f .NOTICE TO TO APPLICAT:If,after making this Cortifico a of Exemption,youshould
become wbjal m the Workers Countenance provisions of she labor Code,you mus'
fonhwid,comply with such provisions or this permit shall be dared mrokrd.
CONSTRUCTION LENDING AGENCY
O I hereby aRmUha Nem is a construction lending agency for Ne lahime ere s of
Z Ne work for which thi p 2,u issuW(Sec.3097,Civ.C.)
4 Lenders Name
7 Lomem'r Address
!slI ceNfy Nal l have orad Cas upph,stion and Wto IMbo
I the ave information is
G. z correct.I a8m to comply with all city tied county rrash Note asate laws eclaing to
w�7 building continued..,real Maby.uNorice mpmarnwive of Nis city he anter open the
UO awve.mmtkarod property for inspection onpoas.
It, 1,,, (Wo)agree to save,inherently ata keep hamlets the City Of Copeoino against
C U lishil,ts,jnhgermea sec anal espenas which may in any way stere against said City
>. Is; in consequente of the granting of this permit.
rpw Q+ APPLICANT U NDERS'I'AN DS A ND W LLT.COMPLY WITH ALL NON-POINT
6) z SOU CH BEGk11.AI'IONS. ,
o re rc p �_'� /o-&o /O_
Signature of AppllcanVContrecmr Dar,
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material Re-roofs
at,defined by the Cupenino Municipal tole,chapter 9.12,am the Health and Safety Type of Roof
Cone,Section 11532007 yP
Oyes ❑No
Will Ne applicant or furore wading occupant use equipmnt Or device which All roofs shall be inspected prior to any roofing material being
-mit haardoos aumnambence as,defined by the Be,Arca Ab Quality Management installed. If a roof is Installed without first obtaining an inspection
Nsnict7 I aree to remove all new materials for inspection. Applicant
Oyes ON.
I have read she heradmus material.myuimmna.mer Chapter 6,95 M the Cali- un erst//a/nds and will/comply with all non point
source regulations.
Health th Stony Code,Secaoru 25305,
esp 53].I unhersanh Nes if the
IdacesatJohntheistoyresponsibilitymthracupant
" Mmeiemnatnns which must he John pia Iouuace,of a mNcate,4Ocuparcy.
Signature of Applicant Date
Owner or au1lariiW agent Data
All roof coverings to be Class"B"or better
OFFICE