99120107 (2) CITY OF CUPERTINO
nuDAtNG DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PURSUE NO.
OWNER'S NAMIP• APPLICAI'1 N 1{RAT
ll 07
i lOf Put Or 1 c)qc3
PIIONL: - - - SANII'ARYNO. CONI ROL NO.
p z Z ARCUITECr/ENGINEER: - BUILDING PERMIT INFO
O O BLDCii ELECT' PLUNIR MECII
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sNZ LICENSED norCONTRACTOR'S DECLARATION Job Description
OZ E O I hereby anion that 1.3Il.enxed unJer,nun p oro or Charmr 9 doh,feeing
F-
v_iFm withScninn"IIXXq of UivivionJof the tlusine,xand Prol"evaionv Cala,rind my licemxc
ee ais in full knee and effect.
IxmClass LC of BRTH REMODEL
O Dane Contra"-'
ARC]if rFcT,s DECLARATION
I understand my plan,.bull he rived as public record,
5
m O O Licensed Prific vional
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OWNER-BUILDER DFCLARATION
='y 1 hereby affirm than I ata Oc n't from that Convn'to"x L,Cooe Law forme -
I-Z< following reamn.(Section 7031.5.Business cal Professions Calc:Any city or county
9 wit J I ox it peninkein t t hes in,prove.rearolikh,(it repair any structure
ce prion t aka y 'tit ,fie nt t h p. mu File g d.l tv neat
'hat he licensed� rrsri tt tI r , nos fthc t a,rxLm,eW tenmere Sq. Ft. Floor Area Valuation
(<ommmsmg wnh Smuon 70x11 of Division 3 or 0¢��pine„.nW Post......a,Code)
or that he is exempt mcmfnnn and the basis for the alleged exemption,Any violation
of section 7031.5 by airy applicant for It p.noil nth tic s the applicant to a civil penalty
of net morcfloor five hundred dollars(55W), APN Number Occupancy ypc
A,1.re,owmaofthcproperty.ontycarploya,whhwrigna'their conlvianicn,
tl1 do the work,and the stmctere is not intended nr offered for ale IS,,.7ti 366
khrooma and Po rc,onaa Code. rhe Contractor',Liecna ww disc,nor apply to in equired Inspections
ncr of me,dor Who build,or improves th<mm,and who fres such work himself
or Ihrmgh his own umpinycss.Prov Idid tom ouch impnwemem,me not immoJed or
offered fm sale.If.howeverhe nnildia, it imRmvemem I,.ole within one rear of 101 — FOUNDATION
oopletion.thcowaer-mtdilm will mwcthe hordennf proving that he did not haila nr 102 — PIERS
Impmvefarpartriven me.). -
❑Lmownmonhepoi,.y..,it pbelyeanromingwhhncxnudcotanacaoao, 1.03 — UFER
n,wm
ct the project Ist nuns n,.Basiand Prorexpinn,Code:)The Contractor s 104 — REBAR
License Law doss mot apply to an owner of property who build,or Improve,thereon,
and who contracts for such projects with a cont odurds)licensed purwiant to the 105 — ANCHOR BOLTS
C.... ors I.Cen,e 1.aw.
❑lan, .empraadcrsce. R&PCho,this ,a.nn 106 — SEWER 8 WATER
Ow I., dATION 202 — UNDERFLOOR PLUMBING
NORKIiR's COMI'FNSA"PION UI[CLA IO
1 hereby affirm under penalty of Pe jury one of the billowing J.damtinns:
203 — UNDERFLOOR MECHANICAL
❑ 1 have and will maintain a Cedicma e of Consent sathinaare for worker's 204 — UNDERFLOOR FRAME_
Compcas lion, a, provided for by Section 3700 of the LaMar Code. for the 205 — UNDERFLOOR INSULATION
perb^rmaneeonheworkErrwmicnthisRntilisisued. 301 — ROUGH PLUMBING
❑I hire.out will maintain Winker,Connpen,mile Innumn¢,ne rey:lied by Section
nal of the Labor Code.for the performance of the work Far which mix peonm i, 302 — TUB R OR SHOWER
d.My work...Col..pco,aborin...needcannoanJPoReynumberand: 303 — ROUGH MECHANICAL
Carrier: Policy No: 04 — ROUGH ELECTRICAL
CER'II FICAnON OF ENEmmoN FROM W'ORK17RS ?r
COMPENSATION INSURANCE 305 — FRAME
(Tbi,section need not be completed if the pemnit is for one hundred dollars 306 — HOLDOWNS
1811X11 nr lrioxJ
I ecolfy mall in the penormance of the work for which this Rennin is ixmml.1 307 — INSULATION
,hall not employ any vctmn in any canner m ax to Ireaorve prbjeet m the Workett 308 — SHEET ROCK
Coni,amuian Laws of Cvlihomia.Date
.Applicant 309 — EXTERIOR LATH
NOTICF.TO APPLICA p IL after making this Ccnilicate of Eaannption.you should -
becmnewbjecttotheworker',Cunlpema on provishms of the labor Code,you must 310 — INTERIOR LATH
Q O forthwith Comply with.such pmvi,ioro ur this permit slmll be deenmd resulted.
z311 — SCRATCH COAT
m
CON S'I RUCTION LENDING AGENCY
a > I herchy at that there is a cnrowction lending agency for the performance 313 — ROOF NAIL
of the stuck he which this P,,I is koted lSee.3097.Co.CJ
0. 0 Lender's Name 501 — FINAL ELECTRICAL ENERGY'
O Z Landrrs Aid,,,,
U C aoirym:trihave rexdmisrmrnearnnInnenmethat mea Mrannnaboni, 502 — FINAL PLUMBING ENERGY
I. E. ctrnrcct.l agree ro comply with all city pad comrty anii^ame,aaf.rote law,rcin ing 503 — FINAL MECHANICAL ENERGY
O Lj fobdro,coConstruction,mi... anJhcrehyawhnriurcprcxnmtivcsafthiscitytocnterumm 504 — FINAL BUILDING ENERGY
rbc xtx(We)tiuse,joined.indforify and
hno,.e.
Fond IWel.agrce joined.indemnify and k hi hat rtl in the City of lam c and laid —
m City ine,.oc lance,. and uapaoxes wmen may m any way allam aswn.r x:dd 505 FINAL ELECTRICAL
U Z City in CAaN1 c DERST g DSA D lids p.nnir.
APPLICANT UNDERSTANULND WILL COMPLY.WrrHALL NryJPf)I�NyTa� Issued by: 506 .— GAS TEST Date
SOURCE Ihr.h11AT] NN � \ �0(/Is_�tV/`V50.1 F7_R4.M_ PLUME31131113
Signmure^lAppl¢ant/Lomrahrr �— Dare Re-roofs 508 _FINAL MECHANICAL
HAZARDOUS MATERIALS DISCLOSURE'
will the applicant or fore mudding ncearant store or banme Emmons material Type of Roof 509 FINAL GRADE
as derned by th.Cal+nlno hlunici,]Ca .Chapter 9.12,and the Hemth and Safety
Calc,See dun 255321x1^ pp
❑r., �11Nn All roofs shall�� tspect�dl�ilct�'toF�t A i1i 'aterial being installed.
Will the applicadtntbnmehoileing«ntpanluse eyaipamtordcvices which If a roof is instr5l1A m7thLFi T •obRI %WiAlQ916tSi, I agree to remove
.mit hazardous air owntamin ims ax nidi by the Ray Arta Air Quality M.anaganem
Dolricfr 4 No all new materials for inspection. Applicant understands and will comply with
1)ye, all non-point source regulations.
1 have read dm hamrdnu,mmeda]s respire pas Sneer Chafer 695 of the
California health&Safety Cala Sections 25505.25533 and 25534.1 ondmmnd that
if tits building dues nut,.nearly hoc i tenant,that n is any regnon.Ibility anally be
acupa of the. ....meas which mux be met prior to issuance of a Caabepe of
°vaoP' Signature of Applicant . Date
own- amhnnnedag.nt oat. V All roof coverings to be Class `B" or better
OFFICE