00060125 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMITNO,
21907 SHATTUCK DR 00060125
OWNER'S NAMH: APPLICA'T'ION SUB DATE
BROWN DAVID A AND PRUDENC H T 06/19/2000
IONih SANI'InRY NO. CONTROL NO.
q ce]Z ARCHITECT/HNGINEER: BUILDING PERMIT INTO
`kL'w F HLDO ELECT' PLUMB MF.CH
Few
<n
5 4-E
i LICENMiU CONTRACTOR'S UIiC1.ARATION Job Description
O<—O 1 heresy(d of f, 1 am Iisxhe B under and
profession,
Chaper 9 gummenemg
F,:^.; x'ith tiulinn 901XI)of nivirionJof, the lousiness and i'ro(cxsiau Codc.and myliceroc _
l'fallR'n'`and111111. ADD CEILING LIGHTS AND FAN
cen< License Class Lid.d
O i u nae Contractor
ce 5 u N ARCH]rECr'S DECLARATION -
F—,0,+; I undcrstun i my plans.shall be u,ed a,public reeordr
top o Licensed Ponfico ml
n y OWNER-BUILDER DECLARATION
w—,a; 1 hereby affnn that 1 am caempt from the Contractor's Licensc Law for the
II'a¢ following rmvm,(Saaion 9031.5,)it niuc,,c and End..inn.Code:Any clly fir county
='o which requires a a,rmil n+canOract,eller,improve,demolish,fir repair aay,Iractwn
oupriorto in i,mqui
ance.also retes the applicant for such pcmn
tio file a signed statement
mat f,is licensed panunm to me powpamNOf[lie contractor%License Lrw(Chapter v Sq. Ft. Floor Area Valuation
mommenciOR with Scddon 7M))of Division 3 of the Basfne„and Professions care) $7B5
fit Thal he is exempt therefnun and fire ki,cic for the itleged exemption.Any viofarlon
of Section 7131.5 by any ap,licmn fora gem a en hied,the mpplieant In u civil pcmdly
of not mem than live hundred dollars($510). A PN Number Occupancy Typc
VI,asowncroohe propeny.al ttry cominlce,wits wages as rheirmle cmnlacha a. 35614007. 00
II do the work.and ons Slatinne is not intended or offered fm sale flee 7(H4.
Hos and Prom, ,code:The Conamcmr.License Law does n apply m a - Required Inspections
or+fit of,a,arty Whotnadd,fir im,noc,mercon.and whodoe,such work Mansell 304 — ROUGH ELECTRICAL
through his own emt provided that such improvements am not intended of -
ofrcred for sale If,haxever,the budding or intposemcal is sold within one year of 50 J_ — FINAL ELECTRICAL ENERGY
a
nuplednn,the owncrhu'JJer will hrwe the burden of proving dun he did noI bwld or
'improve lot pmpo,e orsair.)' 505 — FINAL ELECTRICAL '
❑1,as Owner of the propeny,am exefu,ivcly contracting with licensed contractors to
umsaum the project fSec.1(),W.lousiness and Professions Citic:)The Cotnracam,
I,iccme I,nw does inn apply ,,an owner of pndwny war,builds or Improve,nlerenn,
and who contract,for such pmjean with u ontracpa(s) Ikemse,l pursuant Of the
Coiducmrs Liccnm Lax'.
0 am ca udcr H ft P C for this rem,
nwmr _Data G.7!9Aw
WORKHR'S COMI'IiNSATI(]. DIiCLA tA'IION
hereby affnn under penalty of perjury Inc of the 4llowing dcdamtions:
I have surm f will mtiaoin u Cenificaor C toelf-insure fur Wnrker'x ,p
'nmpemminn, ;is , led ler by Section 3]1111 of the Labor Core. for the - .^
performance of the work fur which mix permit I,issued
❑1 has,and will aiainmin W�rker'I Co mida,nio.I Insurance,as required by Section v
91110 of Ibe Labnr Cade,tiff Ilan IanGnnanac of the work fur which 1111!,Ise nit in
na
11
sued.My Worker's Conrl+rrtion Insurance currier and Policy number are
Came, 'POI iey No.:
CERTIFICATION OF EXEMP'NON FROM WORKERS'
3 '
COMI'ENSAI'ION INSURANCE ,
(This section need not be r.,u,i ed if the permit is for one hundred dollars
(S I W)or Ic,,J
I cerlify Lha in tha pc,lb nnnanee of the wink If,,w16,11 Thi,permit i,issued,I '
shall not employ any person in any manner so as a+become subject la the Workers'
Compensation Laws of California,Dae
Applicant
NOT ICI:TO APPLICAN'1:If.aver making this CenlGenle of Exemption.you should _
7hcctnnesubjccuo lc aWofle,,G.nrpcnsafum pr. Won—Ir the Lbo ar Coda You nml
Q Q fimhwim comply with such provisions or this permit,hall be deemed revoked. _
4 C CONSTRUCTION LENDING AGENCY 7 rsh affi
1 harm that there k a f,nstmetion leading agency for the perfi+rmwrvc
cmc work lint which Of,pe mil is iscncd(Sea.3109],Cis.Cl
Q Leadcr's Nanta
1,deli's Address
V Q I coni fy lhot l hmc read this application and sale l hal l he those 1 nfivmndnnk
La. ,Ir. correct 1 agree lin of ipy with all city and downy ommana,Ind,ane law,re Luing
Q C.) to building construction,and hereby oratorio,reproenlaives of this city to enter Muir
W the aMn'cneminned progeny fur impaction parfums.
F S
(We)agree to sacro,iadcmnifyned keep hannlos the City of Cuxr inu against
fn dabilllle"judgana's,ca,1,and"',an'es whlan may in any way accmc agmn,t raid
U Z C'ny in sequence ofd gaming.1 ti Ls permit.
APE A VDER - NDS AND WILL COMPLY WITHAL NONI�INT
Soli c�LA -�- Issued by: Date
� ylro
Slgnwum nl'nPPlleam G�n¢acmr Date RC-roofs '
ff AlARDOUS MATHRIALS DISCLOSURE
Will
applicant
I,,
future hui . anra.as
rcrx mantic ealloasil
Type of Roof
md, by theCapninbfunicipail Condc,ChRpmr9.11,tnA the Health andlSofcty
Code,SOc 25532(c)?0
yc'
)(irva t All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occmpont use equipment or devices which If it roof is installed without first obtaining an inspection. I agree to remove
ni,namrdous air contaminant,a,defined by the Hay Area Air Quality Management
i'u"? all new materials for inspection. Applicant understands and will comply with
❑Yes XNn all non-point Source regulations.
1 have read he haiaNaut mamtials tegaio,oums under CM1ape,6,95 of the
li",
alifomia Health&Safety Code.Section,2551k1.255 33 and 25534.1 undenund that
the building docs�nut ctirreLmWlyI1hIla'Iv1eI Pu anant.lhal h i,n,y respnnrihilhy m notify the
cupanl or the rcyulan cnN -- —usl on amt Priiir m Irsuuuce of n C'cnilicum nl s Signature o(Applicant Date
All roof coverings to be Class"B" or betterwns"m:nnhonnvl agcm G� Iu -