00080105 CITY OF CUPERTINO
BUILDING mvi5t0,�' p T CONTRACTOR INFORMATION:
PI lip
IN I I.OING ADDRESS: PERMIT No
OWNER'S NAME: ANVI,ICA1'IIl tDl
IONS: `30 SANITARY NO. CON'I'ROI.NO,
,Cm% ARCH]I'ECTIENGINEEW _ 11UILDINGPERM1'1'INTO
O C - RLDG ELECT PLUMB M1:01
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LICENSED CONTRACTOR'S DECLARATION p
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z5 ? IherebyNrml that lamHcensedmade,provisiomofChorale 9(commcrdng BREAKROOM d"INOZOV" tion -
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A t-; WIIh Scylla.7000)ot Do 111:,11. I�lyjylCallI'll]Polin...n14 C11:Ic,1lnd Illy Ecull.e
xa. I,in Pu res. .
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An, hill Ee L S DECLARA
C u O 1 understand my plans hill M rocJ a1 public record,
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C Licensed Pmfec•ional
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OWNER-HU1LDER DECLARATION /
ce='In I borcby corm,Ihat I:all drolla hmn the Convuemd%Luan,c L:Iw ror the -
I-Z a following reason.6reium 7031.5,Business and IhnMsinn.Code Any city or county Os O
F C which requires x Invmlit In mnamct.aller,improve.demolish,or repair any swcwrc
e
Sw Prior alts l.smmm,al.n motor"tbclglpl'¢ u
anll a,ach lsrmin file.,signd llacmmnl
al. mat he is licensed pursuant n the provisions of the Commcmr's License Ww(Chapter v Sy. Et. Floor Area ala. io
Qvlmmm�ci m;whh Section 7000)of Division 3 of me Husinev,and Prorexaion.v Code)
..,that be to a cripl dmrefmnl and Inc hu...I'a!the alleged emn,law..Any violminn
of Section 7071.5 by any apPllemt for a permit will'he aP11i'mot nl a civil 1-111 00
of not none man rive handred dollar,(55011. AP Occupancy Type
01,u owner of the grogra ,or my enodoyoc with wages as their%olc ronlpensm]nn.
will do he work,and([or arunure is no(Intended or offered for sale(Site.70W1
l inol and Prolowirnl Cale:The Contractor-,1)«mc I,Iw does not apply to all Ltl ed IOIIS
ownerrol'protect Who builds or impnwe,themon,and whitebait such walk himself 21712 — UNDE —LOOR f-'CLIMBING
nr thrnugb nil own employee%.m3%deal that ouch ire rowlnctu,are not immnded or
arered n.,ga)e.or,howeve,rme building or ,up in'I1 sold within one year ser 301 — ROUGH PLUMBING
omptaion,the owner-builder will have me harden of Proving that he did not Mild or 302 — TUB R OR SHOWER
nlprovC ror propose of sale.(.
01.eewor, if PrL,rW.,it atural.,ing with rcen.ed couraetan,n 502 — FINAL PLUMBING ENERGY
Immet ole rrojao(sae.7(94.Hesia—,art Profe,,or,Ctde:)The Cla manor, 506 — GAS TEST
"all,Livert,c docs not apply Ise m owner of propcny who builds or in oue,am:.nvnI.
and who renta l for such project,with a contractors)licensed Pm,ouml to ole 507 — FINAL PLUMBING
Coo rector',l.iceno,Law,
01 am exempt under Sec. .H&I'C for 1111 reason
Owner, (late
WORKER'S COA11'IiNSA'TION DECLARATION
I hcmhy afrtnl ardor peva'iy nrperjnry o w of the lidlowing dcdantions:
J 1 have and will n xintein a Certificate of Consent to sdGinwre for Worker'sComp.nmdoll. a, Ptoujo for by Simla.. 37011 of Ibe Labor Cato, for the
perfmmancc of the work for which this panni.is maid,
01 have and will m.....all Worker's Cal relo(ion Inmr:mce,all nquircrl to Scmlon
.3 70)of the LrMr Cado for the performance of the work for which too Pcrmil is
i sued,My Worker's C Pcnwd 1n1lns-.urTencc cart.-rr and Policy
�nu chcr'a�m.
Came ✓rtllcy No.:ky,.c�t�J�_�
CERTIFICATION OF EXEmrros:I OM vORKIiRS' _
COMPENSATION INSURANCE
(This Ica inn Lord nal he enmpincd il'the panni.it for ono hunted dollars
1$1Nb or los,(
I crony lha in mo performance of ma work for which this Permit i1 issued.1
shall not mnyiny any rour In any ramur so its it)hom(((e subject to the Workerv'
compensation('vel a'Califomia.lime
APPl m:uu
NOTICE I'IT APPLICAN'1:i1',afar nuking do,Cenilimm of Eamnption.You sbnuld
Mrome sobjcc.to the Wo ler%Compw
ondnp
n rovision,of the I-Ms Curti you rust
Q 0 fonhwilh clearly with such pookinns or this peralil vhn'I bedaemed revoked.
CONSTRUCTION LENDING AGENCY
a , I hcruM1y oflinn that mere is n umomclion lending agoncy tar the perfomlancc
of the work whist this Penni.i,In ueJ(See.3(1)7.Civ.CJ
/z Lender's Name
mc
7 Z Lcndcr',AJArc11
V C) 1 certify that I have read this application and stale that the above infonnminn is
rant.I agree t cump'y with all city and cswoy ordinuncc,and sate Inw,relating
f) mbuilding vrmuelion.and hereby xmhorim rlimeor mile,of Wil airy m can-1111
Frs.7 .he ahuvemrn.ioncd propcny for inspection Purposes.
y (We)agree....ay..inJanrily and keep huanlels the CiryofCarom'..agolns.
Vi liabilities.judgments,coos and eepeme,which may in any way accrue against said
VZ City in comuquence or the grunting of this Penni..
APPLICANT UNDERSTANDS AN DW .COM PLY WITH ALL NON-POINT Issued by: Date
ER ULAfIQitN. _
slguumre nl'APP IcxnUCl avast... Dale Re-roofs
IIA- )OUS MATIi ALS DISCLOSURE -
WIII.he opplicam or 1Lmre building:ecupaut salm orham➢e ha:aNtar.numdal Type of Roof .
asddinod by the Cupertino Munlclpal Codc,Chtgncr 0112,unA the Hoolth and Snfc(y
Code.Section 255320V O Nn .
All roofs shall be inspected prior to any roofing material being installed.
Will the modicum or fnum building oAupanl use cgaipnmnt or device%which If a roof is installed without first obtaining an inspection, I agree to remove
oulttt oLarons air conamm:lnu an deroed by the Buy Area Air warty Management P Applicant Comply.ill new materials for inspection. A 3 licant understands and will Com I with
0Yes ON. all non-point source regulations.
I have mud(hit Imiali us materials mitieriento under Charm n.95 A the
C.R omin frontal&Safety Code.Sections 25505,25533 and 25531 I undcr.wnd.Int
trial building does no(currently have a mnum,that it is my re,onsihiliry to neatly the
tsocapanl of(ht mqulremmat%which ma,(he ran prior a issuance of a Cenirrao of _
a°pan`y' _ Signature of Applicant Date
w..'L5 All roof coverings to be Class "B" or better .e
Owner or o uth mud agent Bac