00030039 CITY OF CUPERTINO - -
[WILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BOILDING -.. ♦ IHMITN 3
O el k— Go .
OWNER'S. ,.
A1PLICA11d!i2`iSDftII1A0
1300
,PHONE: e SANI IARY NO. CONIROLNO."
aeY. ARCHITECFIENGINF,ER: ' NUILDING PERMIT INf0
OO❑ &A )4\ a,_ Q BLIP ELECT .L PLUMB h11iCH —
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1.1ceNscu CONI RAc 3RS DECLARATION NEW MAUSOLEl�1
I nereb norm mm l a 3 oI do,a awe, - ir oru,Chapter (commecein 'Description .
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rpt win,see,io.andelDivisnan Sol dlueada,es,and rmresnan,code.olid l„y lactase
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so CARCHIHICI'S DECLARATION '
f-=O I 1 understand my plans shat[be used as public record.
g w Y �'' 0 9 2002
ui c O Licrn.ed Pnsl'es.iaml
OWNER BUILDER DECLARATION
IKu” 1 hereby iflim,,bra I nm sump,loan Na Cnnonern,[.icunse I." on,,be .-
F Z Q following noon.(Section 7031.5.Basin...and Prnfessamo,Code:Any d,y or county dllJ7����C7
which require,a Penni,m croomm arer,improve,eemnl6h,m reps.'any.wcmrc _ 1�i
a, primoors issunna.olso,ryuircs lbeupcirlI'll sochpemd In Nle::signal statement '
that tie I,levicisted ptesmara to the provisions of me ContractioCs License Low(Chapter 9 Sq. Ft.Floor Area
(commencing with Section 7001 Division 3 ar the Business ane professions Code)
or the,he is exempt Iheminnn end the brv,fnr Inc ldl,ed cacmp,im, Any v,.Irtioa
of See inn 7131.5 by any ap,fcar,Inr a parmit subjects the aprlicam m a civil perelty
of not mate than five hundred dollars(S5ulp. A L-• V1114 Occupancy Type
❑Las owner of the progeny,or my employees with wages m'their sole comp¢ma,iun.
will do the work,and the structure is not intended m uffered for sale(See.7 co. 101 — FOUN��y�iT��s,1 p
Basile"and Professions Code:the Contractor:License law docs nm apply to on TA Tns ect10n5
o, r of property Who build,or improve,merenn,and who e«,xneh work himself 102 — PIERS
dnrnngh his own employee..pro,med mat such impevanam,are net intended a,
oaared mr aloe.v.I woe,. he Dundas or improvcmem is sold within non year at \ 103 - UFE R
iompletion,me owner.buime,will have the burden of proving that he did no build or \\
mpose for perrync or vle.6 i ' 104 — REBAR
❑I,:a.owner of the prnporexclusively contracting wahbaaseaconlraC1O1f1O - 105 — ANCHOR BOLTS
em,wct the peace,(Sec.7Go.Basin...and Pmfewions Cwea The Com,acmr's
LiaocLaw doa,nal p,Inanowaraofpn,pcnywhonoima,�..vr ove.wlaeo 106 — SEWER & WATER
and who cunlrob fnr inch projects with a conrac,orts)lieamed punumn to the
contractor's license law. 202 —,UNDERFLOOR PLUMBING
nlnexelnl'Irude,See. B III rcrmOld,ransom
Owner Dae 203 — UNDERFLOOR MECHANICAL
o 204 — UNDERFLOOR FRAME
WORKER'S COhl l'IiN'SA'IION DECLAItA'DON
Inemty-fi.unde,pea .(per;ary onear the rolmwing declarations: 205 _ UNDERFLOOR INSULATION
.6❑ we l oand will mairwin a certificate of c:aocu m self-insure for Worke„ 301 ROUGH PLUMBING
ComPersaaon, as provided for by section TIMI of the Labor Cale. for he X02 — TUB R• OR SHOWER
Ie6nnanc
re On the work fnr which this remail is i,,a d. .. v
01 have and will maimain Worker's Compensation Insurance.as myoired by Section 303 — ROUGH MECHANICAL
37W of the Labor Clair,for,he performmeec of Inn ad for which phis permit is
.,and,MyWmker.�Coaapeosaaonlouramecamicrundg@PaJicynnn,berare:. 304 — ROUGH ELECTRICAL
Carrier.� /
`� Policy No.: �yjr 0„ 9/ .
CER11FICATION OI'KXEMPIHON FROM WORKERS
COMPENSATION INSURANCE
(Thix section necd'n,11 be cnn,plclnd it he permit Is tut nuc hundred dollop '� -
cslanorles'.) - 305 — FRAME
1 cemdy Ilial in the gerrormaaa of me work for wIrish lois germil is....ad,I 306 — 'HOLDOWNS
shall n,r employ any refs..in any manner v as to become subject tofhc W ken'
m'cn.abo Laws t.cafirom »ie — �a G_t`Y_ 307 — INSULATION
ppbcant 308 — SHEETROCK
NOI'ICET PPLIG\NT.11.afennaking lM1n Cedificme of Exemption.you should
become sdh rvuo the Worker`.Compensation onvisions of the Lobar Cade,you mnsl '
O O formwimnor,lywith such p,ovilwalor'his gemotshall be,lornadroakea, 309 — EXTERIOR LATH
14 CONS'I'RUCfION LENDING AGENCY
F" nmrehyanimn that nee,.a construction lending agency for the pirformance 310 — INTERIOR' LATH
ya ofthe walk far Ishich'his prmiIisissued sce,317.Civ.C.) 311 — SCRATCH COAT
c Lenders Name
p y 1111acr1Addre„ 313 - - ROOF NAIL
v O IeerlifyEdII....nedlhi,a,licalhmand s,a,ematme'anonmfomnatieni, 501 — FINAL ELECTRICAL ENERGY
(r c—11 1 usl'ce no comply will,all oily and anmty onlinanas and sbdc lawn rdming
o u it,building construction,and thereby authows,repesentriofthiscitytoenerupon 502 — FINAL PLUMBING ENERGY
m the an,Ore)artie,incned o, ryfnrio�caoahaeex. 503 — FINAL MECHANICAL ENERGY
P. (we)usrent,cost iandc,,yuadkeel)haoin mea it of Cupertino gait,sa.t
vIn liabilities,rydgmonu,ensu and expenses which may in any way accrue agnilnt said
z atymconseyneneeofinesmnangonni.pe,mit. 504 — FINAL BUILDING ENERGY
APPLICANT UNDERSTANIjS AbOkWILL COMPLY WITH ALL NON-POINT
aRCEREGULATIODE]/_ ,Issued by: 505 — FINA ELECTRICAL Date
ohne ofn'prcam)conbad„r Dme .Re-roofs — .
pint oRDDUs MATERL\LS t store OsuRe x507 — FINAL PLUMBING _
Wilby(epC.....ln,,f rai,jpICoe Cron sal,eorhal di harmdouxmamdel - Type of Roo
;ode,Sed Section me caperlmo hwoicipw ewe.cb:a'Iet 9,1z,aan,be Ilcnlln aaa 5°f"y 508 — FINAL MECHANICAL
Code,Semon 255T_(u)'!
oyes 11 No All roofs shaffi69nspehtel111 Lr tGdtfj D&fing material being installed.
Will me apgb�ant or a hubdms by
yll Area
Air Qualf desanagement If a roof is in5jI0divnr101lNld'�'t o♦niktigMN11\16spection, I agree to remove
which
emit haWillous air csnnxm r futs a defined ov the Nay Area ip Qm or Management
Dismeoren ONO, all new mateTt4,4'oun.jPl*� Am318p146n�76R1q,and will comply with
all non-point
6S&t9" W8t6os.PLYWOOD NAIL
I hnce rrne Inc hm.,Nuus muwriuk requimnronu under Chuper r,,o r`1 Ian
cahebuiaingdoxtotcur Cwyhaveaan.ant.tht it I% yrespo.u.1uneenram 0he '603 — ROOF BATTENS
If1-fron'Iingesta,n...rannnyhavea,enbe bear,,
iva,n ,onesibimymnmiry me
Onuptial of mu re9ai aovn wb'�cn..'Lee be onset ado,m h,omme airs.cemniram of '
ce'cony. C ,
/ Signature of Applicant Date
o — Lamod;rd zsen 6care "�- All roof coverings to be Class "B”or better