00100163 CITY OF CUPERrfINO
BUILDING DIVISIGN PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: - PERMIT NO.
5101001.63
OW NF.R'Sr'15}ttFE ,
_ APPLICATION SUR DATE
.10/24/2000
PHONE: _ SANITARY NO. CONTROLNO.
❑rc Z ARCHITHC'UHNGINEER:
PWC p BUILDING PERMIT INTO
H6 6 BLDG ELECT PLUMB MECH
Z 5 m= LICENSED CONTRACTOR'S DECLARA'T'ION lob Description
CZE❑ 1 cowry affirm mdemand I um demaunder provisions"r Chapter,9(ennlmencing _ -
Fa,,Cen with Section 700foof Divldon3"fthe Business had Professions Code,and my license
in tie sfull 1 r e d B ,
le U`Ie cl c „ Pool—/SPA,
C aa0 G or
ARCHI'TECT'S DECLARATION
all lo I Iunderstand! {plans sit al be used a;priblic mcoNs
..in
I
ti .retained , OWNER BUILDER DECLARAI ION
I thereby Itn ,.
PI f tl C I t License Law
for
the
fell h g t(S 7031,5,H d P I .lode A y
ail, r firmly
w 1 a permit to construct, R improse,deriolish,or repairy structure
ce .
a prior si...ans",alla require,(he appleentf h preennit toFile signed.tt t
that In is filausld,nourant the paroi,mrs orth Coutur License Law(Chapter9
(int g 'ths t 700 rDm 3 or 11 dl 1 :Code) Sq. Ft. Floor Area �Valua[idn
:it that h is ptntmr d[lie ba f the alleged exemption.Any violation - X644000'
orsect nn 70315 byany mi for a pent,I'i me app,cant e n
v v Peart
y
or no,snore than five hundred dollers(S500). APN Number ' Occupancy Type `
❑I,na"wall-I'lie initially,-1 dYerdroae.wish wages as theiranle centpamatltn,
will Jo the work,and the smmmre is not Inrended or ,if..J far sale(Sec.7044, 3 4i
Business and Profeasi6m,Code,The Contractor's License Law does not apply In an Required Inspections ;
owner of property Who'bullac or improves thereon,and who does such work himself - '
or through his own employees.provided,bat.ueh itnpmvemen¢are no,intended or -
offered for sale.If.n"wever,me building or improvement L.rola within one year of 1.03 UFE R .
acar i�o:morn qu—bailer will base he Damen ti pulsong that he digin n nttildar 104 — REBAR 'ina .
❑I,a,ne acr of propetty,am cxcwllealy comarecang with licensed eommelors to 107 — POOL/BONDING---i
aanttmet he pmjm(See.7044.Basin..and Prefexaiona Codec The Conneaut', 301 — ROUGH PLUMBTNG
License Law does trot apply to an ownerof pmlromy who bodes or improves,heeum .
and who contracts for such prciee,a wills coolntemrfs)hr....ad abroad m the 304 — ROUGH ELECTRICAL
Centrucmr's forecast,Laos-
EI fair,asir rare,Sed.
aw..❑fair,axcmptuadu5ee. ,BAlIs , ,Umosen 517I272- FINAL PLUMBING ENERGY
Owner Date 503 — FINAL MECHANICAL ENERGY
WORKER'S COMPENSATION DE.CLARAI(ON
—
..1 h'col,acorn,under penalty of petiury one of following declarations 506, GAS TEST
El
.
51.0 '— FINAL PLANNING-
❑ 1 have ata as rovede a a cby ieme or cons nt to ee],.baura for workers 51 1 — FS NAL POOL
compensnce as provides roc by Soction 9redu of he Lahor elle, For.lila' -
perfonnance of,ho work for which Ihls'Iwnnit is;Seoul. '
516 — FINAL BUILDING
El 1 M1uve he will iminVtin Worker's.Cosnpenn,of t hu'n.,k t , such hi by Section ,
3710 of the fortes Coda far the pulsurancec of the work fm which tare permit is '
coed My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Perky No, - -
CERTIFICATION OF"EMRI'ION FROM WORKRRF'
COMPENSATION INSURANCE' ,
- (This'cctmn need not be completed if the semi is for one hundred dollar. ^
(S 100)or ln,s.) '
I certify that in Wo perrnrnrame or the work for whieh this permit is issued,I
,hall not employ any pn'nm In any manner so a,,o become.or to It,W..kers
'
Compensation Law,of Cnlifomiv.Dole
Applicant ,
N(JTICE IOAPI'LICANI1 If,alcor making tlsis Cenilicmc of Exemption,you should _
bce,ii athpen
e Worker.Compensation pro,kimbof the Labor Code,youmum
Q mmO forthwith comply with-such provisions or In'pennitahall be deemul mvekal.
F Vl
CONSTRUCTIONLENDINGNG AGENCY -
�" I hereby which this there Iss meed(See
calling a far the f mans
K' or tau work Im which this pnrnJ,is issued(See,3097,Co.C)y per er '
W Q Lender's Addre
der's Ad -
� Lendress -
I cervi fy that 1 have read this application and ante that the above infornmtion Is -
s
correct I agree Io mmPly xith all city and county ordinances and Stam laws relating
fJ rot huilding eonmrui trod hereby aunburlm representatives of this city to enter upon -
�s W the abuse mentioned ptopm'I,li,r InNsectlnn purposes. '
�y 0. - (W4)ogres m save,indemnify unJ keel IwmJess the Cily of Cuper,ina again,
F 4 liabilities,judgments,costs sad expanses whub may in any way acemc ogains,said
U City In consequence of the gmming of this perm;,.
SOURCE REGULATIONSNDS AND WILL COMPLY WITH ALL NON-POINT Issued by: ' Date
Ssgnulare of Appli,callContraatur DateRe-roofs
MAIIDOUS MATERIALS DISCLOSURE
w'm me api,uanm er rmure mdleins oc'c'upant scorn or handle ha.ardous material Type of Roof
ns defined by the Cupertino Manicip rl Cala Chapter 9.12,and the HUJth acid Safety - -
Cada Section 2553200'
El yes El No
All roofs shall be.inspected prior to any roofingsmaterial.being installed.
Will n,aircournt nrfumrebaud;ed tccupaB yAeaAirQu,lit Mmidswhish If a roof is installed without first obtaining an ins ection, I agree to remove
oma hmnnlohe aneomnmi,amurelannedbythe Bay Area en Alrrrao, olit", hent g P g
District, -all.new materials for inspection. APP P Meant understands and will cont Iy with
ID yes 71 No
all non-point source regulations.
1 ansa scud the aaaardtnts snateriuls requiremema under Chumer 6.95 el the
Califom'a Heahh de Safety Code,Sections 25505,25533 and 25534.T understand that - -
ittheauilJia,does no,arosed,have a mmeal, hat itismy reapaerladdy to notify the
occupvn,of tae requirements which must be mel prior m issuance of a Certificate of
Uranium,
of Applicant Date
- owamoraunianredagenl 1 Date, All roof coverings to be Class "B"or better
OFFICE