01110114 ct sun owe nPv sioNNO CONTRACTOR INFORMATION:
PERMIT
BUILDING ADDRESS: PERMIT NO.
10123 N WOLFE RD 01110114
s'NF.R'S NAME: APPLICA71ONS S DATE
•W THINGS WEST 11/27/2001
PHONE: SANITARY NO. CONTROL NO.
C u Z ARCHITECDENGINEER: BUILDING PERMIT INTO
tOu C BLDG ELECT PLUMB MECH
�< T= u I l II
aF- LICENSED CONTRACTOR'S DECLARATION
O y= 1 hereb .Pum that]am licensed under provisions of Chapter 9(commencing Job Description
= pr.iai p e O . N WA j �ry
with Section oral ofDlvisinn3 of the Busincsa and PmlessinnyC .�d
jy I,� iscefull lone anile L 3
rc a Licenle Clnss k 0 Lioc^»
C F
Date w/ f C uacmr
m I' ' ARCHITECT'S DECLA 1
_i I.adnrsmnd mY plans shall he asetl as public records s
3 x O o Littmed Pmlesxional
OWNER-BUILDER RATION
3, i boa(Sm
hereby that I sen exempt fromrom thflate Cessions is License t.uw for the
C?a following reason.(Section]03LA Busincsa and Professions Code:Any city arc ante $_50 O
�I F o which requires i p.also to i.the r alter improve,demolish,or repair any structure -- - - _ _
3$ prior toitz iasuawc,also rtquirea the eppliamfw ouch permiuo Olaezigned nemmcm - - qfe- �s - - ------- -------
(commencing
- -
(commencttn with SmTanrm the of Division
me the Business
usinLewons Cer9 s3'YV�V S;IisPp.p.'pq;,iS, ,I ,sq Valuation
or maxi a ingamrsfu mfor wind the basis o dr,a i edess enarini A ,vi Code) I } '.'j �; _Y zV,CC_11-tt771.`h[fvV- .5.�. {, '.t'
or the he 7 31.5 b shere(rom and the basis for be sllegad etrmant to AnY violation -
ofSection 7031.5 iv any applicant fora permit subjects the applisanno a rivil penalty
of not more men fivenaneredeonars(s5gl). 101%I'N DATION Occupancy Type
0Las ref the propeny,u my employees with wagesas com
theirsole pensation.
will do the work,and the.net..is not intended or offered for sale(Sm.703,1, ],O 3 - UFER Required Inspections-,
Business and Professions Cade:The Contractor's License License Law does saw apply m m q
owner of property Who builds or improves Nthereon,and who does such work himself 104 — REBAR __
or mugM1 em
his own ployees.provided that such imre provernems anot intended or
offered l'or sale.If.however,the building or improvemcm is sol within one year of 105 ANCHOR 7 BCLTS
ompletion,te howner-builder will have the W rde
n of proving that he did not Wild or
improve for purpose of sale.). 106 — SEWER & WATER
__- 202 - UNDERFLOOR PLUMBING_ �. . .. _._.-__.. .-
O 1,es owner intthe p(See,7, ,Businively c praning ns Cmlicensed Contrtors to
PLUMBING-
construct the patient(sec. to a,owner
arta professions code:)The Comacmn, 2 03 - UNDERFLOOR MECHANICAL -
- aldose Law docs not apply to an owner or property who Wilds se improves merean,
and was contracts for wenn projects wise w
a namaw(a)licensed m Ne
pursuant _ 2 04 - UNDER$LOOR FRAME
' - Conuac,nr's License Lew. .
0 l am eaempJ under Sec. - ,B&P C for this reason 205 - UNDERFLOORINSULATION
wuer Dutc 301 - ROUGH PLUMBING
-
WORKER'S COMPENSATIONDECLARATION 302 - TUB & OR SHOWER
I hereby affim under penalty of perjury one of the following declarations: 303 - ROUGH MECHANICAL
0 1 have and will maintain a Cenificam of Consent to self-insure for worker's 304 - ROUGH ELECTRICAL
Compensv0on, u provided for by Section 3700 of the Labor Code, for the
performance of the work for whim this permit is issued. 305 - FRAME
01 have and will maintain Worker's Compensation In mmism.as required by Section 306 - HOLDOWNS
37M of the Labor Code,for the performance of the work'for'which this permit is 3 0 7 - INSULATION
issued My Worker a Compensation
Insurance currier and Policy number art
308,; SHEETROCK
/ Cametr' t ' s Policy No: • . t, f
CERTIFICATION OFEXEMPTION FROMWORKERSi, ` -3'09r x'EXTERZORLATH'
••
COMPENSATION INSURANCE ' .- . .. ----310 ,
—_
' -310'. ="INTERIOR-'LATH. - -----n•.�;.�, ;
phis udian'need not tic completed if the permit is for one hundred dollaa 311" - SCRATCH COAT
(511107 rar less.)
I certify tin rformence of me work for which this - 3 13 — ROOF- NAIL ^• -•" •_ -.__- . . ..__ .._ .. . ..-..
p tiwiwwad.l 501 - FINAL ELECTRICAL'rENERGY
shall no,empI any so as to become subject to the Workers
n on
manner
Campeau; w ate .502 - . FINAL PLUMBING ENERGY. .. .. .
N01'ICET IA . .rar ; an.yaaanowa 503 - FINAL MECHANICAL ENERGY
become subject t the W kels Compensation provisions of the Labor Code,you must
QZ forthwith comfit with such provisions or this permit shall b,deemed revoked.
ZR . . . . .. - 504 . FINAL--BUILDING. ENERQX- . .
"CONSTRUCTION LENDING AGENCY
'
a- 1 hemb,airmt mat mere iw a canatmnihm lendmg iii rar sen Perram;anee 506
JZ Le — GAS TEST 505 - FINAL ELECTRICAL . .
of the work for which this permit is issued(Sec.309].Civ.C.)
fy' nder' Aame
Z Lender's,Nunn.-' --"" 507 — FINAL PLUMBING
�. " ...
U Or 1 certify thnt 1 have read this eppliwtion antl sate Nat the above information is 508 - FINAL MECHANICAL
te+C[s comm 1 agree to comply with all city end county,ordinances nM sure laws reining 509 - FINAL GRADE
0,U to buildingconswetion,andherebyamhorizercmmaativesofihiscitytoenterupon 510 - FINAL PLANNING
�,,, W the abovementioned property for mimetic.pm oars.,.,
t ,0. ifNe rce to save,indemnify and keep hanNess the City of Cupertino against 514 - FINAL PUB I C
F, rA If ilities,ju gra ms,costs end expenses which may in any way accrue against said
U try m conif nee of Ne gsv,tin (mss permit.
LIC NT UN ERSTAN .'D WLLLC M1PLY WrfH ALL NON-POINT' Issued b
'OV :REGp .ATI y: Date ��L/ -O/
Sr ofAp am/Cmntamor - "' - Re-roofs
Dme _
' - - HAZARDOUS MATERIALS DISCLOSURE Type of Roof ^ /
Will the Capetorlanae Wildinge,Chaptnue2.haMlen ealthomenial -_ _ -- ..- _
as d,finelSm by me Cupertino Municipal Code,Chapter 9.12.and me Health and Safety
code,senior sss33W7, -. . .. - r..-.a:.�;V ..: • • 's ' �' "s', � ] _ .. it ..
oYes's r.ONO ...All roofs shall be inspected.prior to any roofing.material.being installed..-._.._...
Will Ne applicant or future Wilding occupant use equipment or devices which
L If a roof is installed without first obtaining an inspection;I'agree.to'remove
emit hvisrdous air contaminants as defined by me Bey Area Air Quality Management
District] all new materials for inspection. Applicant understands and will comply with
ores ON. all non-point source regulations.
I have mad the hazardous materials requirements under Chapter 6.95 of the
Calif enith&Safety Code,Seciions 15505,25533 end 25530.1 understand that _ _ _
if puildi gdues not currently haveemnamaher it is my res nsibi' sb ndrify the
cupanrpf the rc ircmenu ic`mua� r nsuena of a Cam t
Signature of Applicant Date ..
•' ''' rorau on d gent Dale All roof coverings to be Class"B" or better '
OFFICE . .. --
"_Y ���, -