00120049 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRRSS:
111710,111NO.
222545 POPPY DR PRECISION PIPELINE 00] 20049
OWNfiR-S NAME: Arvi.iCATION SUB DAI'E
GRIMF_S BRUCE I 5294 RAFTON DR 12/07/2000
'. 191ONH:
SANITARY NO. CONTROL NO.
(408)723-1411
C C O ARCHI"I'EC d:NGINUhR: BUILDING PERMIT INFO
l= BLDG CLEQ' PLUMH MUCH
dad
E ucBNSencQNTRArroR's nLicLaA]dDN lob Description
,NE Z_' I hrr,by affirm Ihm nm na
1 lianl lima,, prnn,of Chyme 1)nrnnmfncing .
Furca wmin
ilM1 Swtion]IIWkd Divi,inn 3nf the Nrs,amnud Pmff,siom Codc.end mYliccn,e
iis n lull an
imedeffect. SEWER LATERIAL AND FILL IN SPETIC TANK
K rc d 2 License c.la,.v I,ic.M
C i U Dam Cmrtmctor
w 3 u AROIII'1'IiCi"S DECLARATION
C= 1 anderseincimy plan,shall M uud as pnMic mated,
�1cep O Incfattd Pmfcssionul
OWNEan emaiDLR rr he ContraON
ctors
1 .....nffinn IM1m 1 nm,Burin Bum the Comrus Co :Any cense Iuw'for the
C ii a fi,tiowin mmnn.IStrout l 7)mm Itnsincx ane I'rlcn moll Cole Any ally nn'aunre
z e wM1ich myuirtn o pcmrit n,conswct,eller,impmvc.demolish,lir repair any sauna,,
e41-
au priofill 1 9 'he fpr I folotchfiction t 11 grcd.n t men
-
'hat he v,ficeloedp :. tt tile aniviki oolthc 3 l Lee(CIaptero Sq. Ft. Floor Area , ttion1
(commitment,is'tn Section 7010) f revision)ofth Business oldP f:.' Cudc)
or that has .opt Ihuatro and the hassfor the alleged exflnptnn.Any vrl,nam
of Section NJ 1.5 by any applicant for a rerinh subjects Bre applicant to a elvidpmnahy
of not more than five hundred dntlar,(5500). APN Number cupancy Type
01.a. er ofrnc propeny.o my employee with wages a,their sole ennten,aBnn, 3421 2005_ 01"S
will do thex'nrA,and the structure i,not intended lir offered fee rule(Sec.]Du,
it cis and firm rmlh.
Cale: Tin,Cnmincmr',License haw hat, an 1pidy to;in Required Inspections
n,f propat,Who build,cr innerme,memon.und who Jre—ech work himself 106 — SEWER & WATER
lir
through hi,own employee,pruned that inch improvements am not intended or
otremd lit sale.If,however,the hu'ddia,lit hmlnd,enem is sold wahnn one year lir 20i' — UNDERFLOOR PLUMB I NG
iimpletion,thf ownerbuilde,will Lase the burden of pmvins Inat he did not buildor —
mpmvefotpurrowifsm,.). 301 — ROUGH PLUMBING
❑Lasower,of Be,pmpert,aneclu,ively contracting with licensed commoners m 302 — TUB & OR SHOWER
nsuuct the pneject(Sec.700,1.Business and Proms%io lis C,ale:)'Me Connaftod,
i ea a lrw mnot apply to am nwnet al property wI hand-,im,nwrs merlin. 502 — FINAL PLUMBING ENERGY
and who commas for,nen pmjecu with a cormare m s)licensed pursuant m the
Chmmrnnr,Licari.Law. � 506 — GAS TEST
01 am exempt ander Sec. .B&P C Ii,nhi,reason
507 — FINAL PLUMBING
Uwn,r FN
II
WRK[R'S CUMPIiNSAr1(IN DECLARA'I'IUN '
I hereby of on under penally or perjury one of the following Jcd;meions:
0 I have ind will maintain it Certificate of Consent to volt-insure for Worker's
Companxminn. 0, pmviMd ter by Scaion gild of the Labor Crvfe, for the
por lattice of the wo,k for which this permit is issued.
01 bare and will maintain Worker's Compenn:vion Ilnurmar,us required by Section _
3700 of the Latin,Code,for the perfomance of the work for which his permit is
sued.My Worker',C'nhnpemvtiolh Innanuae carrier and Policy another are:
Carrie, Policy No.:
CER I'117ICNI ION 0I7 Bx IiMI,TION FROM WORKERS'
COMPENSATION INSURANCE
1'His,eclion need as be completed it the nanot Is for one hundred Jnllurs
15HER)o,le'.0
1 lenity That in the perlLrm.7umc of the wolk lilt which mis inamil Ir ivcued.I
shall not employ any person in any runner m as 10 become subject u7 the Workers'
Ceau,n,atlnn Law—rCulilbrnia Delo
Arldiemal
N(n ICE;TO APPLICANT:If,alter making tni,Ccrilicam lir Esrmption, no should
hcce rally,mt o Ib,War kit's Caulper,au on pnwniom of lire LaMn Calc,You Inset -
0 OonhIlmhwhh, ply with such provisions lir Ibis peit,hull be declined a
Jul IokcJ. _
Z ZI CONS'IRUC I'ION I,L7NDING AGUNCY
a , 1 herchy ahmr that duce,is a construction lending agency for the performance
the work Ba which this pimrit is issued(Sec.31N7,Civ.C.)
L Q Under',Nahie
is z Isndcr's Address
C.7 C I brit,that I base raid this updr,arlon and,tam Iha Ila uhove Inhinnaliun Lc
fY [.n cored.I agate to comply with all it,and county ordinance,and state laws mlaling
U m building innsttuclion.and hereby authonLc represenelive,of this city m enter upon
} Wthe afxwe-manuoned progeny for inspection pminne,.
F" G. (We)agmemsave,indemnify and Ease,harmless the City of Cuperino against
V1 Ilobilitien 1u(IElinceB,cn,IX and oepcn,rr which may in:aty way auric afminat nd
U z City in crioneyuence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date /� ���
SOURCI7 REGULATIONS.
sighramrenfnpprcarttContractor Date Re-roofs
HAZARDOUS NINHIRIALS DISCLOSUI(E
Will the applicant lir fuare building«cugant,firm or It"n®ardnus maenad Type of Roof
lis dclined by the Cugrer inn Municipal Calc Chegrer 9.12,and flue Health and S.cfy
Cute Session:55321011
0 Yes 0 N All roofs shall be inspected prior to any rooting material being installed.
Will the vpplicmn,forte Iniddngoccupanl use cyuipmcnl m devicos which If a roof is installed without first obtaining an inspection, I agree to remove
,mit ha,ardons air contaminants as defined by the Bay Area Air Quality Management
enlnrn all new materials for inspection. Applicant understands and will comply with
ores CNo all non-point source regulations.
1 Leve rend Inc hamnnus muariuks ,imnenl,under Clasper 6A5 if the
Caliloolia Health&Safety Code.Sections 25505.25533 and 25534.1 understand that '
d the milling does not currently have it tenant,that it is my ms,msibility to many the
o,ccupent of the nyoimments which muM7 act ct poo,It,issuance A a ecrlrcam of
ccupancy.
Signature of Applicant Date
Ownefnr refill agent Dee All roof coverings to be Class "B" or better
OFFICE