01010002CITY OF CUPERTINO
CONTRACTOR INFORMATION:
BUILDING DIVISION PERMIT
BUILDING ADDRESS
PLRptI'010002
10338 MIRA VISTA AV
U
OWNIiR'S VAMC:
AI'I'1 C lID SUI{ ly\' i
G1
NAM
HONE:
SANITARY NO. CONTROL N(l.
ARCIIIT FCI'IENGINECR:
BUILDING PERMITINFO
BLDG 1I_ECI' PLUMB MECH
hIC.IiNSF,D CONTRACTOR'S IECLARNI'ION
Job Description
I harvhy alYlrni ,hal I al's heawcJ under pmvtoolo of Chapter 9 (co'mnencing
7IXHIIn len3of ,hc Husincv, and Prule,xitO cn,i riadsu
POOL
isin lullSection
se>k1'",y
in lull force: pHc
,are s( Y]O Comranm L511
FINq�„ED
ICu,eJ E I-Aic TIONS
ARCHll
1 unJen,anJ Illy PIran,AR shall the.S-publicrecoN
JUN 0 6 2002
Licensed Pratessiovl
OWNER-BUILDER DECLARATION
I hereby afGrn Ina, I .,it exempt from he Commmnr's License Law for ,he
following mmon. sialion 7031.5, Buehm,s mal Paide ,ion, Code: Any city ser county
BUILDING
which requires a pem,it to ennamet, alter, improve, demoli,h, or rery,r any 9fadam
Prior to its issuance, atm requires the uppliemin for such varied to rile a.signed emmment
S Ft. Floor Area
v'
1]�1��`)���/h�)�j�q,,/�ion
$3WWrUYJ
that he is heciwJpunuan,mthepdrv:uolS of the Contractor's Licenu Luse (Chapter 9
Betide„ Pndesxioni Codd)
(commencing with Section PBaB of Div isiun 3 of the and
n that he is exempt th,mfmm and the hall, far he alleged ,oa ptian. Any violation
.
of Semina 7031.5 by any uppli,am for a rental subjects the applicant to o civil penalty
APN Number
Occupancy Type
or not loom than rive hundred dollar%650).
35,70'2021.00
cons
❑ L m nf'le pnpedy n aycc w.,n wor rd I..N..le
Required IIISPCGtIDIIs
(,pc 70,44.
m �dlLaw lot no u (,So, 914,.
w.11 au ltue 1, ogle
me wolk, Inti ,ha mmcuac h our ctor
s 1l
e Gala'fnc Contractors l.iconw Lawdoe, apply ",.,I
Bontaot amt Iedy mw nil
103 — LIFER
Whonb
at prnl, ow wen o,ia or Imprn see at o-h nnJ who nee wink pelf
nflco,d gh hlx own that such lnprol arc nn, intended nr
104 — REBAR
however, building is sols
oBereJw,,ale. It. erwe,d,winaiavetofurden,e'mTln,old he did nor year it
nrmoellothe will have me naNe".n pro,ms,nm he did nm nand or
107 — POOL/BONDING '
"a'wailoinaer
pm,e purlxwcn-
❑I,d, owner if he pmpeny. am exclm.vely eammNng with licensed mndmcelsrs u,
301 — ROUGH PLUMBING
L,maraca he project (See. 70,14. Besides, and P..fe,sh,m Gale:) The Contractor',304
— ROUGH ELECTRICAL
.aeme law it,,,not apply In ala owner of pmpeJy who builds nr improve, the.,..
tad who eommats felt .such project, with a rontraem fol teemed pursuant to m`
50 — FINAL PLUMBING ENERGY
Commclor's Lieensc law.
❑ I an, e,ea,pt under See. ,B&Pcor this nuoun
503 — FINAL MECHANICAL ENERGY
Owner Date506
— GAS TEST
WORKER'S COMPENSATION DECLARATION
510 — FINAL PLANNING
I he uIllr„ under ..If, it velp,Y one of he ti,unwins uclarati 1,.
'a
511 — FINAL POOL.
1 fill,, ;,III will ,oalmai„ a Cemdta,(e of Cn'„en, m Leu:;rare hof Worker,
Cmelpe,o,iu,, ,,, pnwidul for by section 370o of nue Lmof Code. vhf the
516 — FINAL BUILDING
Iwo rom,amca of me work for wldn, tela pemJl 1, „wed.
(:11 hall,;I I will mnlulein Worker', Compensation Insuntm,, its required by Section
3900 of the Iahar Ga1o, for ,hc Verfannancc of the wad Ibr which 'his pent.:, is
looted, II W.n�rk� Is. Co'mPemmian Insurance curz'ierl'nJ I''n3lic`ypnumM1cr uym
03 Policy No.: jNC
Cunder _yc%/11 _
Cl-R- I'IFICNI ION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thi%waction need no, he completed if the permit is for one hundred dollars
o iffi, or less.)
I ecroy that in the performance of the work for which this perm:, is issued I
shall no, employ any peolo. in any man wr ,, as m hccon,e hjcc, no the Workers'
Co'npenaa'ion Laws of C.1ifom.a. Dum
NUI ICE 10 APPLICANT: It, ala, nicking This Ccnit.cate nl facmption, you should
beconm suhiccl to the Worker's Con,pensa,ian pools..,, of ,ha Lab's Cn ]I, You mus,
Ile(hw all courtly with ouch provisions or this per ns' Ihall he declined revokcA.
CONS 'I'kUC'I ]ON LFNDING A(.ENCY
I etichy al1.m„hat there is it con,wc,iou holding agency riot the,wrfonuanee
of the wink for we;cls' pull pcm,a i...uvnal (Sec. 3097. Civ. C.)
Lender', Name
Lender's Add,,,,
1 ccdll JG 1 have mad oris application and spm (hat the starve inli,rn,mion i,
correct. 1 a • e it onq,ly with all city and county mJ.n tacev and .ape laws rda,ing
,obuild.n cons ,tion, and healthy carbonize mpmunmtivesafmis city m enteruq,n
the aM, mon ped pe)peny for imp,Oion puaPwcs.
( c) me or save, :„dem d kce(I hunnles,he City or Co,errino again„
,
Gaal it , j smeou, awts a x m, whichmar in any way aeem, against laid
City in , quence if it. gra ting fay., pem,h.
2 -O
APPLI( .TUNIIBRST NE I D ILL COMPLY WITH ALL NON POINT
Issued b Date
SOU .li '1 TI( :.
C
Y'
/ a2-wool
Re-roofs
—goamreoiAppucanmimtrortor Dale
HA'/ARDOUS MATERIALS DISCLOSURE
Will the applicant or fu(um building occ'upnm xoom or handle h:vurdous materiel
Type of Roof
o, defined by the Capon in,, N%.pal Cao, Ceapll 9. 12. and the Iivnbh and Safety
Code. Sec, out 25532'al'f
eve, No -
All roofs shall be inspected prior to any roofing material being installed.
Will he algtiaam or Pape ba;hlimgoKenwnt ata... iip'neo( of device, wnia,
If a roof is installed without first obtaining an inspection, I agree to remove
emit h,rzard,msn nanNnal, ldefined hy,ec Italy Area Air Quality Managnnanl
t `
all new materials for inspection. Applicant understands and will comply with
\' `1 No
all non-point source regulations.
ad the enmnlons materials requirements under Chapter 6.95 of the
(h&Subtly Cole. Sections 25505, 25533 and 25534. I undenwnJ that
'
ose, not eurmn'I l Imam, (ha i, i„my res,ms.hild, u, na(ify the
rcqu.nmenu wi ch n (be met pr.nr,o issuano, of o Certificate of
4.orhan.d
Signature of Applicant Date
All roof coverings to be Class 'B” or better
an.d ag,m Date
OFFICE