02070141 OF CUPERTINO
CI eat DUNG.DIVIiSIiONPERMIT CONTRACTOR INFORMATION:
8M80DRPPCIFICA DR PERMIT
APPLICATION1� UB DATE 1 ` HIKIDO, DDS 07/23 /2002
PHONE: SANITARY NO. CONTROLNO.
zz ARCHITEC(ENGINEER: BUILDING PERMIT INFO
C F BLDG ELECT' PLUMB MUCH
LICENSED CONTRACTOR'S DECLARATION
z 5 h 1 hereby affirm that 1 am licensed under provisions of Chat 9(commencingJob Desert tion
oz- y' p`°"i° Chaptere TENANT IMPROVEMENT (DENTAL OFFICE)
0—_F with Secnomeand lir D;visn,n3nnne nndness ana Proressionseode.and sur license
a m of is in rue Come and efreet. �".1 A ■ C
z m a License cross u<.a G'4111�IG
ou
3 a. D - Contractor
a.ti ate ARCHITECT'S DECLARATION
" O g 1 underhand my plana shall be used as public mcoNs DEC 1 0-2002
�u O O Licensed Professional
a OWNER-BUILDER DECLARATION
w'4—' 1 hereby affirm that 1 am exempt from the Contractor's License Law for me � II DI
t?a following rtason.(Section 7031.5.Business and Professions Code:Any city or county UIL 0 7 Cj
2=0 which requires a permit to construct.alter,improve,demolish,or minor any structure,
a,3 prix 1 't issuance. Is y thef suchpe u' fl signed statement
that he is liciumed priatiabomthinewifame,ofthCu mer r.License La (Cher..9 36S3I30tQ 2 o 0*aY• r f Valuation
(co ting with Sectors 71100)of Division 3 of Nc Bosine dProfe. ions Code) (�(k:\ 1 - sds tit f Ilfn�:
or that he is ciempt therefrom and the basis for the alleged exemption.Any violation
-of Section 7031.5 by any applicant fora permit mhicaa the applicant to a civil Penalty
.or not mora than me hundred dollar.($500). 101 ARN i ONDATI ON - Occupancy Type
❑Las owneronne property.or my emPlor«s with wages as mebame rompetwtPon. 102 — PIERS
-will do the work:and the strvcturn is not intended or offered for sale(See.70,11q, 103 — UFER
Business and Professions Cork:The Contractor a License Law does not apply m an Required Inspections
owner of progeny Who builds or improves Neuron,and who does such work himself 104 - REBAR
orr th through his own employees.provided that such improvements memo are not intended or
cofferedompletion,
for sale.If,however,the holding or improvement of n sold within one year or -"'-10 5 =- ANCHOR- BOLTS - - - - ----' -' -- --
completion,the owner-builder will have the burden of proving that he did not buil)or
itnvruver°rparpn.eor.tale.). 106 - SEWER & WATER
.. snwouofthe pmlmnY.timexclusively roniroctlnewith licensed cmunistonto ""'202 UNDERFLOOR-'PLUMBING _
construct the project(sec.70,14,Business and Professions code:)The contmetors 203 — UNDERFLOOR MECHANICAL' .
.� and wh taw das not apply man owner of progeny who Wild,se improves thereon.
- -.and vector', ions for men protects with.a.ront wmro)can w Purs lit to.N __204... - UNDERFLOOR FRAME
. Comrucmr's License law. ...-
0lamexempt under Sec. :B&PC for this reason 205 - UNDERFLOOR 0)INSULATION
e a 6��Z&a 301 - ROUGH PLUMBING
WORKER'S MPEIN DECLARATION 302 - TUB & OR SHOWER
lhereby arrtmunder p<naltyatpe,quryone of.tire fouowingdeclarations: 303 - ROUGH MECHANICAL
0 1 have and will maintain a Certificate of Consent it) elf-insure for workers 304 - ROUGH ELECTRICAL
Compensation, as provided for by Section 3700 of the Labor Code, for the 305 - FRAME
performance of the work for which this permit is issued.
01 have and will mention Worker's Compensation Insurance,as requited by Section 306 - HOEDOWNS
3700 of the Labo,eode.for the perfo uranae of he work Or wnicn suis pemrit is 307 - INSULATION
issued.My Workers Compensation Insurance carrier and Policy number am: ,_
..308 r SHEETROCK _.......
canters ' '' Policy No: .
s,1. 9;-i=.i EXTER'IORI•LATHS'•
s CERI'IFICA'rION OP ENEMPTION FROM WORKERS't
COMPENSAnoN_wguRANCE'.
' '(This section need not be completed if the Permit is for one hundred dollars 311 ' SCRATCH COAT
($100 in _ . ..,,.,_.313. - ROOF -NA-IL . .. . . ..... .. . .
1 rectify Nat in the Performa of the work for which Nis permit is issued,1
shall not employ any person fn.mo,sy 2Z zr ,sabjea m the Worker, S01 - FINAL ELECTRICAL'`ENERGY''
c,�°co��p� 502 - FINAL PLUMBING ,ENERGY .
r N4,roAP_A1,Wrmaking th'.Certificate orExemption.yousn9la 503 - FINAL MECHANICAL ENERGY
Z bee roe s bjce,to the Worker,Cmarroupar,mvikimr,if the Liflaurced,you
O O form m nilly withhp .nsamn p iIhaebea d oked rest 504 - FINAL BUILDING ENERGY
CONSTRUCTION LENDING AGENCY S05 — FINAL ELECTRICAL
a1 hemby uRrm Nut then is a construction lending agency for the performance 5 0 6 - GAS TEST _
Q a `. -ofth kf h hth p t' dSee.YA7.Co.C.)
LcnAcName 507 - `FINAL PLUMBING
Under',
_
Ada 5081- 1
INMECHANICAL
1 germ that hall.city
and Lmmmctthn o f i
m O en ct 1 greet pie with a tr dordinancesdstatem relating 5 GRADE
O.01.Wilding construction.add hereby autho - p pati"e.of this city to enter upon 5 0the above-mentioned progeny foramixanim pumosce.
oat (We)agreetosave.indemnifyandkeepharmlesstheCityofCupenin°against 51 B RKS
U!) liabilities,judgments,costs and expenses which may in any way accrue against said l�
(.) Z City in consequence of the gmming of Nis Permit. // fD
APPLICASTUNDERSTANDSANDWILLCOMPLY'hmiALLNON-POINT Issuedb Date
- SOURCE,REGU \ ' g Ye
mum of nppliranveomatrtor Date r Re-roofs
HAZARDOUS MATE _S DISCLOSURE
.. veli me appy i .mare nail ' occupant baro or hand na:ataoas mamnm. . Type.
as J hoed by the Cupen a 'Manic' Coda Chapter 9 12,and t Health anJ Safety
Cod,Scaumn255J2(nl - `t ' i91! •". .Ifin. .' 1 Tt '
.'Dues 0 N -All roofs,shall.be.inspected.prior.to.any roofing material being.installed.. . ..
Will the applies or funum buildin upam useeyuipmem nrtlevices which If a roof is installed without first obtaining an inspection, I agree to remove
emit bacmdous air contaminants as def by the Bay Ante Air Quality Mowgement
Oilmen all new materials for inspection. Applicant understands and will comply with
°Yes '° - all non-point source regulations._ , .
I have read the h Nom mmedals"moment,under Chapter 6.95 of the
California Health&Safety Cade.Sections 25505,M533 and 255th.I understand that _if the Molding does not currently have a tenant that it is my responsibility tonality the
Occupam of the requiremems which must he met pnor m Issuance of a Cenificme of
ccupancy.
Signature of Applicant Date
tillomaatnu aeaagen, � Date
, All roof coverings to be Class "B" or better
OFFICE .. _. ..