00040129 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PHRMI'r NO.
^ 1
OWNEW S NAME: APPLICATION SUIT DAI S
PHONE: SANITARY NO. CONTROL NO.
O aiZ ,\RCHITECI'R!NGINEER: ❑UILIIN'(i I'ERA11'r INFO
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I)LIHi ELECT PLUMB MIiCH
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1.ICh:NSEU CONnoodanOR'SDECLARATIONWor-Khat" Job DesCPIpn00
S v,C l amhy affirm Ih'aa I ant Ilccn,W lama......rtVo v or CM1upaa 9 acomy liter,
m�lid
with Sem lon7gNp cf DivisionJofanc Business and l'm@.cions Cute,and mylieense
a-�'� if cefnn corer 8nd crrecl /a�q�r�// L
W.W¢ License CClesx a Z� Lie.n—((, GG// '✓ ADDITION AND REMODEL
a O Date Al s DEC for
'-K','+;+ 1• ARCHrl be use DECIANAIcord
i nnJcrannJ nsy plana.hull lu used as public rtu,rJ.
F y -
w=p 5p Lecowd I,ml'csionalOWNER-BUILDER DECLARAHON
/
I nernm affirm that 1 am exempt front Inc comments-is :Any C La.v fur the
following int,. (Section...L5.h.i firs and oic.d cions lis o,Any cm nil roomy
or E a whim rcyuiro n remsio a amswm.applicant
i t for ra demolish,nil repair any.wren
m that heor isiccr dpurs nntto res provisions a]the Contractor
Livem,le a Law(Calemem
m%- the he is cmct Scrliouo the provisions a 3 of 1 id R000rx coal lle Lv,ioa, ode) Sq, Ft. Floor Area a t10i1
or thm he is cwith Swoon]INNII nl Division 3 rl Inc Huxincs and Pml'c n,t ul I
or See he is 31.5 b ahcrefmnt middle ba.i,hn the sl,the w1wea,,Any viodod,
of hot.,n a than
1.5 by any hundred
doll dollars.
a pcnnia.unjern anti nrplicnm w a aril pewlty
of hot manHsebandreaa"nar.aswj. APN Number Occupancy ype
01.as owner of the pmpeny,or my employees win wages as(heir sole compensation.
will do the work,and the strucmrc in not intended or offered for sale(Sec.7W4,
Huxincs,and 1. 1...I..,Code:'rho Contractor's License Law dues nil",ply m an lRequired Inspections
oar of pmpcny who builds w i;aproves theern•mal who does such work himself .
lend,els own umpluycs.Provided that sire improvcmems am not intended or
offered for cam.If,nwc,r,the building o i"hpm,cmem is sed,aitnin one yea 101 — FOUNDATION
completion,the"wne,bvilder will have the Named"f proving that he dm not nnild 7 02 — PIERS
improve h,r puHmse°:sees). —
01,ms owner of the propcny,am exclusively contracting wile licensed contrvicem a 103 UFE R
.educt he p,,,jet,(sea.nun.Hasine,,cad 11 d,i"o�code:)The Contraon" 104 — REBA R
.can.Law docs not apply lot nw,let of pmlmny who nalt,L orimpnwev the,"I.
anti,aha conteclx for.such projwt,with a contraclnr(.).neansed pn,xmma,",he 105 — ANCHOR BOLTS
Contractor's License Law.
0 l am esemp,ander Sec. .B&PChatmx,eo"n 106 — SEWER R. WATER
Ovocr nate 202 — UNDERFLOOR PLUMBING
WORKER'S COMPENSATION DECLARATION
203 — UNDERFLOOR MECHANICAL
Ihcmhy aeon mdcr Pcnnlry of rysjury nuc ul'Oe follnwingJmlurullons� -
0 I base and win andnt:hn a Cenirrate of Consent o xIf i...., for Worker's 204 UNDERFLOOR FRAME
10 Compenwlion, as provided for by Section 371X1 or the LeMn Code. ter he 205 — UNDERFLOOR INSULATION
m
perfoanceoftheworkforwnichthispermitis sued. 301 — ROUGH PLUMBING
01 have and will ourits.Worker'%Compensation Insurance.asrequired bySection
'302 — TUB R• OR SHOWER
971x1 of the IAImr Code,for the perho nonce of the work for which Ihir permit Ix
i11.1d.yyw"/tkrrxC"open.ati"nlnse;nreaimh,andPirtleym'"bCfJf; 303 — ROUGH MECHANICAL
Carver:_ Pohcy NO.: FROM 1• KERS*
=1 tg4Ya'Y; N hLCEMPI'IO.N FROM WORKERS* - ROUGH ELECTRICAL
{'GNrr f.a/f ,pµ,{�jSAT10N INSURANCE a0 — FRAME
(Ilia velm evil mnnecooldetedifthe"Fill isfor lame handled dollars — HOLDOWNS
($10(h nil Iea..) "1
I cendm[lie mat ie p,rmna we of the work bar which this emit is issued.I 07 — INSULATION
shall not employ any person in any manner so as to become subject m the workers 308 — SHEETROCK
Alf,he
Compensation IANs of California.Dam - /•
NOTICE
OTIC n, hould
/U- 309 — EXTERIOR LATH
NOome aDrlto he Wnr1w it cell..:making mla his ac io., col Labor CI ynuaan-I _
nuc"mc,"njwu"witw"rkcr,Ckimr,,atmn corn.ion."rand cines e„dc,r.a m..a 0 — INTERIOR LATH
O p fnnhwiah comply with such provision.or this permit snuff he decnmd ruv"kcd. -
Z � CONSTRUCT ION LENDING AGENCY 31 - SCRATCH COAT
I hereby BRrn that,here is a conshnmion lending agency timer performance 31. — ROOF NAIL
of the work for whim this pecan is issued tsce.3197.Civ.CI
y p Lenders Name 50 — FINAL ELECTRICAL ENERGY
o z IAnaersndnrt"s 5 .2 — FINAL PLUMBING ENERGY
U O 1 verity that l nave,cad this uPldsalo nand sone halm,ub,„o inhmmaf"m is
r 1 agree o comply with an city and coaaay ordinance,and stmc laws minting 03 — FINAL MECHANICAL ENERGY
4 :.built.
O U m abovngcontioned aper heminspection furrows.
anetivo a[thix city wenmrurym -
�, m thea h(We)linonmpmpenyainif, edwe,harmle 504 FINAL BUILDING ENERGY
(.. 4 c, vgmc1" cost indemnityand keephamyin the City nilcapcniniagain. -
fn liahilities,judgmcnu,toms and expenses which may in any way a«me agaiot said 505 FINAL ELECTRICAL
C,7 Z CITY , I he 6.a.ing of this permit.
APP ICANI 1NDEBST \S AND WILL COMPLY WITH ALL ONPry/NT s 506 — GAS TEST Dale
SOU CE R`,� PEO FIT Z
Le,4T10 IS/ y:
Signe co nPPlicon✓C ct"r nam Re-roofs
HAvARDOUSMATERIALS DISCLOSURE 508 — FINAL MECHANICAL
Will hheapplicant or future bu'ciing,wcupam store or handle harnrdoas material Type of Roof—
a,Jeaincd by the Cueni
pno Municipal Car,Charter 9.12.and the Health and Safety -
CnJa Suutl"n 253121.)" 5 (� - r„t (�I �r� pt\'Is'Llsl�
ave. ONo All roofs sha19r1�9te[[1�mSpedte7a7 ( r tpp .Ii'}{•ty/t,Il'Allrr(`i�nyLT❑•'115napte�{ri�a'l being installed.
Will the upplicam Io name nailing occupant use equipment or devices which If a roof is in5ra'lled witkoa Oki 6PItl Oja'Irn i 99 A. l agree to remove
emit har mous air contaminants as defined by the Its,Arco Air Quelily Munagemedt
District? all new materials for inspection. Applicant understands and will comply with
❑Yes ON. all non-point Source regulations.
I have read the hmubtou,Itralnols rululmmran,under Chapter 605 of the
Culifomfa Iludan he Shely Codu,Section.25505.255:33 and 255:34.1 and-land Ina
it the building docs not currently have"mmol,that it is my responsibibly to notify me
the:cyan mnu• wlhic nh i..uanec of x Ccnihc(am of _
°" ra"`y' ' ts( Signature of Applicant Date
_
ova aannod.cd ascot All roof coverings to be Class •`B"or better
OFFICE