00030216 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS PERMIT No.
STEELING RBAB _ I J
OW'NER'S NAAI `rte -R BAY APPLICATION SUB DATE
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1ONp: _ - HEMIES - _ SANITARYNo CON'HIOI,NO,
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MXZO ARCH]rECDNO
EINEER: BUILDING PERMIT Hero
pp RLIHt ELECT PI.UNIB N1ECH
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LICENSED CONTRACTOR'SDECLARATION
I hereby aRnn that an Iireamm
eJ under pvisioof Chapter 9(a,mmencing .1017 CSCrIpIl011
p<it J witn sretion via)erni.i..im///111,,,•••jjj(((nne eame„and rmre..in�/c `µay(cense
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Mot full Inrec upJ cr c O_ ry�(( � n/
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Liven
NEW SFDWL: 3385 LIVING SP. , E85 GARAGE
Live `N7- Ti C.mbn,elnr
3 a — I Aµ'HITECT'S DECLAR I
u O S 1 undermnd my plans Ball to used as public records
wo O Lianwd Professional
°'a• OWNER-RIIILDI R DECLARATION
MM, I hereby ttllitan hull Inaan fYmn the C'n road is Liren,c LowFar the
re ,
C Z 2 following .(Section 70315 LBoo ,and Trotsesa Code Any city or county
I O which pictures u permit to construct,aler,iinpnrve,demolish,or octal any structure
zpdonniu is,uancq alw reyuircsthe applimm f,rloch permium flcasig„eJ slmenlvnl
a3-
that hcislicensNpunuummthe provisinnxofthe ContrarorsLiver.,Law clarper9 Sy. FLFIoorArea Valuation
(commencing with Semon)tip)of Division 3 of the Businerl and Pmfnssim.,Cole)
or,hat hear ex,mpt,barelium bad the heals for the alleged oxer .dior.Ally violation
of Section 93I5 by any vppllcam fora formai,whicell dee tmplieam b,a civil penally
or ,at lnare than Five hundreddollars 45an. - APN Number Occupancy ype
❑I,as owner of the pro,to or my employees with wages as their sale compensation.
will do the work,and the,rucmrc is not intended or"Bead for rale(See.704bi, G .r
B sinew sad vmfc,,ion,Cale The Contractor,License Law doev a",apply to an Required Inspections
,00f pbopery Who builds or prn er Ihumad -ouhim
nn, nwW,does work self
owner
im
through hi,nwa caydoyaro.proea
vided that ch ntq)rov,me„b,are a,,,intended"r , — ROUGH MECHANICAL
offeurl tor sale,If,however.the bt ^0?
ilding or Improven,emt is sold within line year of d v
completion,the ow'nervbuilder will have the burden of proving that he did not build or 304 — ROUGH ELECTRICAL
incl for pro "re Lir,ale.). '
01.as ownerothe pmpcny,ineaew,iteycontracting wid,licensedcommrmr,to 501 — FINAL ELECTRICAL ENERGY
Lin,n
I et Fire p,,,,,(Sec.9044.H-mr,,and Ill code:)The Commnor, 505 — FINAL ELECTR I _
cense I.aw door, an apply to millivolt,of prefecny who builds or improves Ihem+,a,
and who contracts for such pmjee„with u contnll"11) licensed purtanl,o the
Commemr,License Law.
❑Lata comfort under Sec. .H&P C for his nano
Owner Deo
WORKER'S COMPENSA IION DECI.AIIAIION ”
I hereby affirm under penalty of perjury one of the loll"wing declarations:
1 have and will maintain a Certificate of Consent m wit-imu,e for Worker,
,C.c,f asution, a provided lin by Section PW of the LuM1a Cale. for the
purfnn axiii r, asire wok lie which Isis fordo,Is 700 o
❑I have and will maintain Worker's Cotnpemwtlon Insurance,as required by Section
SIW of the Labor Calc,for the performance of the work for which this permit is v
issued.Mays keC Co}yep/yrsminn Insurance carver and l'alic 2nnitec „
Carricr,NJ, np 51 /11$• policy Nn: _��
CH 'IF ION OE E SEMI9lON P (IMWORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is lin r
one hundred dollars
/
(S l tip or less.)
I renify that it the perform ar,c of the work for which,his Penni,is i.,.aucd.1
,[ull nae employ any Imrrtun in any nuts"cr so as a,hccoac subject b,the Workers
Campensmion Lew.,of Calitomia.Date
Applicant
NO]ICE I'O APPLICAN'P.If,after making this Certificate of Exemption,you should
become alto the W'orker's Compensation provision,of,he Labur Cale,you most
Q O formol ith comply with ranch per,War,o this .it shall M domed revaload.
r CON S RUC'I ION LENDING AG ENCY
' 1 hercby tiffmnhat Farr,is a cmRwmibd lending agency for the performance
of the wad for which It 1 nail is issued(Sec.8099,Civ.C.)
yp der,name= Vp�
5 Z Londere Address .
ecnlry Wm I have read Ibis applicn,ion and,state(hat the abuseltdbna lion Is
k. F correct.I ogace m cos ly with ell ciy and county ordinance,add same Inv,relating
Q V
to building consrudion,and hereby aathorite representatives of this city or enter upon
the aM,vcanention d property for iafoectian purposes.
F y (We)agree mcmc.indemnify and keep harmless the City of Cupenlna against
W liabilities,judgment,cope and egmacs which may in any way ancme agala,saidCity al
APPLICANT UNDERSTANDS AND
permit. L-
' 6
ANU WILL COMPLY WITH ALL NON-POINT Issued by: '� Date
SOURCE REGULATIONS.
Signature of ApphcanalContranm Date Re-roofs
HAlARDOUS MATERIALS DISCLOSURE
Will the appdcam orfllme building ocupnnl store or handle nmardoa,n,medal Type of Roof
ars defied by the Cupcnlnn Muolcipal Cole,Chapter 9.12,and the Hwlth and Satety
Code,Semon 25532(ob"
❑Yes 0 N All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
nit hwaN"u,an eons nalrom s as defined by the Bay Area Air Quality Management
i,ricdl all new materials for inspection. Applicant understands and will comply with
❑vt, DN" all non-point source regulations.
1 have read the lot, cus materials requirements under Chapter fi95 of the
Calilbmia health&Safety Code,Sections 25505.25533 and 255311 understand that
if the building does not currently have o tenant.Nat it it my resperoibiliy to notify the
cupem of'he rc uiremmat which must be abet poor Fir isnuunce f a C• ;Orme of
OOccupancy. Signature of Applicant Date e
Owner tr aa,na be ,ge - 'z� r a All roof coverings to be Class "B" or better
OFFICE