00090037CITY OF CUPERTINO
CONTRACTOR INFORMATION:
BUILDING DIVISION PERMIT
BUILDINp ADDRESS:
PERM I'iNo.
OU'NCR'S NANIF.6F,2 SHADOWH I LL LA
Hix DESIGN fNC
APPLICATION WIPA -
ONE: X I N CAO
o
swan RI NO,
V. ARCHITECTIENGINEER:
— C.5
BUILDING PERMIT INPO
❑�
BLDG ELECT PLUMB MCCH
w
LICENSED CONTRACT OR'S DECLARATION
Job Description
1 hereby affirm that I Int licensed under pmviuiom of tm
Rat,
I r,Chapter Code. license
p� with Section7HW)dDivi.ion3ormelluaine.a and Pn,(osinm Cade. and my license
is' full (lace and ellect.
calm. LIG.ll
U Da(e Ommtcrr
FURNACE
t, AHCHI'fECT'S DECLARATION
g 1 undcmund my plum,halI be. d as public records
/
'j Licnasxd I'rufcssional
y -H
dh.0 I r rano tH .n Ile Contractor's
1 hnohy vsecr thus 1. cmntpt lines the Contnu7Co e: An w lily I.. the
a' following (Section 11131.5, Bmines, and Code: An, city of county
uimon.
sae. derali
O which teyuirc., a Pemba re seamen, apes improve. JPermith. or repair
V
requires the applicant for Permit ed lamermin
Sy. FL Floor Area
Valuation
drift ill I, lectedaasorstc Carbon Licenssig(acJ>lmemem
in the Division the Co
thathbeirci 9Code)
Br,u,rs andPmaw(Chapter
,,IIIScauion7000)ofall
Ic 3 of the Business and i Ede)
Section 70171 ofhe
is
b sis ion. A.,
or that be Is esmnpt iMrcirom and the basis bode alleged uuiwi lion. Any violation
that he a em
may dred dm ma a pno.h .onjeet, roe apmhc Ana to a ni.il pcotdty
an
APN Number
Occupun
.f act l than ,
.fact mita than mm humo-m aounra ($soo)
❑ I. in, owner of Jae pmPcmY or my employees with wages as their ole compensation.
352240G2. Rg@ired Inspections
will do the wad, and the umemm is not intended m sod erect for sale (see. 744.
Bo<ines.a ant] Profession. Code: The CmmmnnrLmanw Law does mot apply to an
of propcny Who nodal or inapmves thmcon, and who doca.uch work himself
urvmf
nmgh his owa c apbyoen. povidet] mm such impmvemems am mot intended or
'
offered for ink. If, houi be budding or hnmo.emeat is %old within one year of
301 — ROUGH PLUMBING
iompletion. the owncrnuilJer will havethe burden of moving that he did not Wild or
mprove mrpmposaofsme.I.
303 — ROUGH -MECHANICAL
❑l.as carer ofthe property.aul excmni,ely emmaeting wilh licensed nmtowbo,n
304 — ROUGH ELECTRICAL
os
neamm fie project (Sec, 7144. Brame., anal Pmfe..w .. Co 1, 1 The Commar
License Lamol apply to ant owns, of property wair hoild, of hr,moo. tmmccom.
w loan
505 — FINAL ELECTRICAI_
and who commas lin wen projects with a coutrach r(s) licensed pursuant to the
Contractors ucemc law.
507 — FINAL PLUMBING
❑ l um exempt under see. , Bx P C for this reason
508 — FINAL MECHANICAL
owner Data
WOIt Klelt'S CUMPY:NSA'nON DECLANA'I'ION
I homhy unit. under penalty of perjury anc of the following decimation,
i I have and will maintain a Carl of Consent to sdGinwre for Worker's
'
Cnorib imt. us provided for by Section PW in the LaMar Code, for the
perllnntunce of the work tour which this pcmnit is issued.
❑ i has, and will narration Worker's Compenamin i 1n.umncc, as recoiled by Secret
3700 of the Labor Code, for the performance of the work for xhich this peribit in
.wed. My Workers Compensation Imumbee ember and Policy number arc:
Carriers Policy No.:
CERTIPICA'I'ION Op RXEN fION FROM WORKERS'
,
COMPENSATION INSURANCE
I Iris section need not be completed if the conto is lit one hundred dollars
I51 W) or Iola.)
1 certify that in the performance of the work for which this permit is issued. 1
'
shall not cmpioy nary arrwm in Any nntnnar io an to hceunw nable,, to the Woke,,'
Compensation Laws of Culil eras. Dote
Applicant
NOTICE To APPLICANT. If. after making this Cmnicam of Ewmption, you should
become subject to the Worker's Compensation provisions of the labor Code, you muss
fonhwith comply with such provisions oat this .it shall be deemed revolud,
n CONSTRUCTION UIN ANG AG ENCY
I hereby of sin that there is a consumer ion lending nseney a,r the PeHmounce
of the work for which this permit is issued (Sec. 3097. Civ. C.)
] Lender's Name
'
Lower's Address
.
yI cconty (hill l have road this nmplic'W inn and state man the above nfirnnannou is
,
cumco.I "'ree 1IIY with II city 1 county V ws unit laws refining
(obuld' y t f JI hY tit ..... t I usttth. 'a' as ne,.'m
for l
is (he above-umationed propcirty pc purposes, .
L (W 1 6 t indemnify dk ph 1 the City fC pen ag+nd
A liabilities. J Jg t t. dxl which y ay way 6 nt said
Cly til granting Inti,p t
1 r U I
`I Uv
ImtNTUND
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINT
D
ISSUe Date
SOURCE REGULATIONS.
Re -roofs
Sig(mrm of ApplicanVConionor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orform Wilding overpaid store orhandle humorous made"
Type of Roof
as defined by the Cupertino Municipal Code, Chepmr 9.12, and the Health unit Safety
Curie. Section 25532(0)!
0 Yes El No
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use allotment or Jenice, which
It'd roof is installed without first obtaining an inspection, I agree to remove
emit hwnrdous air ammminants as defined by the Bay Ami Air Quality Slanugemen(
)inricR
all new materials for inspection. Applicant understands and will comply with
Yea El No
all non -point source regulations.
I have read the to rmduus materials requirements under Chapter 695 of the
California all & Surety Code. Sections 25505, 3533 and 25534. I understand that
if the building dins not currently have a mount, that it is my resgmsihility,, notify the
occupant of the requirements which must be me( prior to issuance of a Ceniliente of
Occupancy.
.'� Signature of Applicant Date -
All roof coverings to be Class `B" or better '
Owner ecdagma Daac
or'man ...