00080022 (2) EBUILDINGADDRESS
OFPERTINO
IVISION PERMIT CONTRACTOR INFORMATION:
COID (::RAFT 1111C; PERMHNfl(a010022
5 h10RW:U-'I-I AV
NI:RS NAM'; APPLICATI(Jxlyf(}�(:31jA2L/)(!I(!I
FF&AT .•i•J'C-=1'WENT'Srai2Ii<ra ;ra w' 1G(sU DELL_ raVE
PHONE: (408) 374-729? SANITARY NO. COVIROI.NO. -
aOIJ ARCIUI'ECT/CNGINEER: RLUG IiLECT BUILDING II'LUAtIiINHO M1IiCH
mwC
a V UU 1=11 LZA L—D L-1
t�-H hI n that I CONn,ad to al r ocCL,II Chapter
Job Description
o H` 1 nems firm Ilial 1 not IiccnsW under f Cho Inc 9lmmmm�cin
y. nrov�dnn.a p s
°—°�—w with Section 7(Mx))ofDivisiou3arthe 1Imim..sart Vrnfesvian,Code.amlmydmns' F-Urd,ACE./ADD AC _
¢y y i,in full�om��I r, err Com¢
R. Liecnw CI:a.,C�� '1?,C?Q N'i.a 4s!,/C15.34+ cr'
p dle
Dale _3 b S DECLAR
3 a ARCIIITIiCI's DECLARATION
I mdermnm my plans shall he used as public records
f tai— J
ce p O Licensed 11ndes,kn al Q
u o OWNIiR-RUILDER DECLARATION 0
I hereby nB1nn 1ha I sen c:en,pt from the Contract-',License Lire for Ide
i—Zj 6 Iialowtng tea.-n.(Section 7031.5.Ilu.lnase an I Ptotc,,innn Gxle:Any city to coumy '
` C which rey.i...a permit in compact,altar,improm,denudi.h,or repair any%ourum
ati
3$ prior to its issuance,also minims the applicant for such Permian file a.signed statement
that he is licensed toward to the provesion,of the Cnntmctot,License Law(Chapter 9 Sq. Ft. Floor Area Valuatidhl
comminuting with Sfflion 7(N10)of Divisum 3 of he Bw um,,and Profession.Cade)
or that he is exempt therefrom and the basis for the alleged exemption.Any viclaian
of Section 7031.5 by any applicant for a Peron subjees the applicant to a civil penalty
,if on(hmam.mrise hand,,,]dol as(55al). AP. 11YU rl3c.(�[7 Occupancylype
❑1.as owner IIIto p oP oy r ply no g.. ,th ......alion,
will J [lie A d the structure is not intended or offerea fear 1 (Sec.76L1.
Basi and I'miessions Codl The Contractor's Liciame Law des,%not applyit)an 3C17. FiDU( fl4rt 3P49tlBts
m r of properly Who builds m minuses thereon,wad.ho does such work himself
or through his own employees.pun-hal that such imp.-semen¢am not intermit or 303 — HOUGH NECF'Inh1I CAL.
offered for sale.If,however.the building or from...e n fit I.wId within ane year of
ample¢-n,mencaner-tin'llaer ,illuoanteburdenolmovingthathemJonb"Pdor 304 -` ROLIGH ELECTRICAL.
improv¢R,r...H,-.col ewe.). .
;(;I s F IIsIn1_ r::a_r:c rR:r.Cn1...
❑umact he pmet.71araeusinissanaly dmmcangwimraen.Thenmmeeaa :y(•17 FINAL GI_UI'ICING
amm,et the sen;ea(sea.,Dior Business and fro, Ia,b Cute)The Contractor-,i. L:r i
and who
Law dtc.Dol apply loon owner of a sum who stitch or improve.mto the
and woo eommer,for engin pmjc<Ix wise a mnlrwmrl.)licetwd Ppruam m the }0fi '— FINAL h'IECF-IAhIJ:CAL
Gmmacmh Liren e law. `
❑1 nm enenpt,Immr sac. .If&PC r-r this rea.an
Owner Diva
WORKER'SCOM10!Ns Ar OND.; LARXI'ION
1 hereby¢flim under penally of perjury one of'be follow if declnmtiom:
I ❑ 1 have and will maintain a Certificate of Consent .,self-insure fur Workers
Compensation, a.. provided for by Salina 390X1 m1 the Labor Code, for the .
p-I tawc ot'the work for which 1111,panni'is isamd.
�ly�'1•hale-fid will mninorm Worker'.Cninpanmrion Imur:ama,no r,.I,,d by Station
'd]do
of the Labor Cole,for the performance of the work rnr which this permit is
i,suits.My Worker's Compen.alion Insurance carrier and Pufcy nuunn1deer am:
rie -
CarA �o—CE'tJTUQ..y Policy No: 6 0 fret'20
CHRTI PICATION OI:EXEMPTION PROM WORKERS'
COMPHNSArION INSURANCH -
(Thi,.,,tiI need nm be completed if the perntil is t'nr one hundred dollars
SI WE art leis.) ,
I verify that in the performance of the work for which this penttit is i...ed.I
shall not employ any toon in any homer In as to become.object to the Worker'
Contpemsaian law.mf Calif uwn.Dam
Appreatn
Nal 07 I'0 APPLICANT.❑;alter milking suis CcrllEcaw of Its anp..on,yon should
Maome.abjectIn the WaaerI Compen,af nPrmi,inn.of the lana.Code,ranmat
p O
forthwith comply with such provi,inm a.this permit nhol be deemed revoked.
Z
f"
CONSTRUCTION is
unionlending
nXNDING AGENCY
thereby which thanhercix.issued ce. lendi ngagency for the peRnnnance
Len the wobrute which this ryrmit is issued(See.3N7.Ci¢CI
i Q Lender's Nano
z Isomer'.AdJres,
'-1p I eerily that l havu read this application and marc thutlhc abuse inllrmaion is
t.., correct.1 agree m comply with all it,and county ordimmer,and state laws aiming
p C.1
:o building con.wetinn.aad hertby.,boom reprewrmttves of this city to caner-Po-
{r] the above-memioned property for inspection purposes.
FC. (Wi)agree r,save,indemnify and keep harmless the City of Cupertino against
N liabilities.jnd,our s,costs and asperses which may in n
any way scene nyaiml said
C> City in a i""na¢c A the grouting of 1111,permit, ..//
APPLICANT UNDERSTANUS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date r�
SOURCE REGULATIONS.
Signature of Applicarmcommolur Dale Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
w5111he applicant or future building accupant.tore fir hand,hum,Nous ntaedal Type of Roof
as defined by the Cupeninn Municipal Code.Chapter 9,12,and the Health and Snfev
Coca Secti
Yce 25532m)? ONn
All roofs shall be inspected prior to any roofing material being installed.
Will the...heard art future loading accopatn use
cyniphent or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit Human..car comamirams as Jerre)by the Bay Area Air Quality Management
Dilanee all new materials for inspection. Applicant understands and will comply with
❑rex 0N all non-point source regulations.
I hove seam the hue.anlnns mnterialx m4ulr.mm�r..under Ch In h 45 fit me
Cold..ma Hewlh&Saray Cn 1,.Sections 35505,25533 and 25534.11 dadtood lbw
If the building docs nor cuircndy lone a fenem,thus II i.Iny m,pon..ulky Io amity the
occupant of tire re air Is which mull be mm pri a of a cenililtim of
occ.'acy. y/3 Signature of Applicant Date
net.1 Date All roof coverings to be Class•'B"or better
OFFICE