01020063 (2) CITY OF CUPERTINO
BUILDING DIVISION, PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMITN0.
20,390 Tl-161 CENTR 1 _ 0102006.:
IiR'S
OWNNAME: APPI-ICA'I'[ON SUIT DATE
02/14/2001
PHONE SANITARY NO. CONTROL NO.
a-Z ARCH]flECr/ENGINEER: BUILDING PERMIT INFO
O O BLDGELECT PLUMB MBCA
y til
>j LICENSED CONTRACTOR'S DECLARATION Job Description '
Oz=C 1 hereby affirm mul l am liceri under provision,of Chapter 9(careneneing
<rn l—on with Section Vlpfpof Division 3attic Businenn and Pnifivocon.Codud.and my license
Y Y% i.v n IiJI I'nrav nm 0.a,-- eJ 04
l O
lemma Lice stns i L I-ie.a ( INTERIOR DEMOLITION
3 a f– 'are
_ Contmcmr _
ARCH I'S DECLAR N
SyC a t unJersunJ my plan,shall be u,cd m puM1lic curd,
a p O License)Pnrte,aiuwl `>
c'es OWNER-BUILDER DECLARATION
1 hereby affirm that I um c.cago from the Carts ,Licanx Law fm Inc \\
Z a' hib"ing reason(Section 70315,Bu,incsn and Prnlesinm Cade:Any Oily tit county
de OwIncI 4 I , , ( II ' P 1 loo P y:olvore
aim pnart if, .I rt' the 1plvtfor such permit t tile if signedtnenrent
bar he is livereedpfroarmr tn,fnowum,mi commican',Litateve h (cnapmry Sy. F[. FloorAr ? Valuation
(comment ng with Section 7000)at Di a n J r theBusiness .d Pr f. s Cadet
,It lint he is exempt Iheri I and the basic for the alleged exemption.Any violation
II Sell in17031 5 by any uppllcavn lin'a hit,nil objects the applianu to a civil Iwnalty
afour none man fivebundrmdodnr,(E511o). APN Number IV,
t Occupancy Type
O 1.as fth prpvty or rnycirplrjecithwagesasm Icmpen.�in.
II I eh is d theI r e intended offered f (Set.70W.
It ,i I' tc,i n ( dc:The C n f -'ljoroo,I' r np,l, an Required ectl ns
ownerf properly Who h Id. e' rpo ve. th I n d h k l .elf ' e
,rthrough n own empl a piovidedthat such mpra,eme. ( I , ,don 101 — FOUNDATIO Q
offered for s:m:.If,however.the building or imprevetnent i,sold within one year of
unnplceion,the owner-badder will have the burden of proving that he did fall mild or 1 C12 — PIERS
opmve e,r pampa of nmol. ,
Oasowneroftheppany.ame.ear,ieaycontractingwinrransedcontraemit)
103 — UFER
Lnr
whom,, he pmjec,see.70W.Bashes,aad Pnrfc......Cadet The Contractor, 1.04 — REBA R
I.1cerne Law docs nor apply to an ounce of prnreny who nail),or improves meram,
and who saurus",lot .,If rmjees will, a corraanor0) Learned na,rrrrrn ro me 1.05 — ANCHOR BOLTS
ri ees� Seoamxrpt airier e .B k P c for this mason 106 — SEWER R• WATER
Uenrr Duecroc — UNDERFLOOR PLUMBING
WORKhIt'S COMPP-NSAI']ON DITCLARXI'ION
203 — UNDERFLOOR MEChIAhiICAL
I hereby affirm under penalty al'Ircrjury one of the follow ing declarations: 204 — UNDERFLOOR FRAME
. ❑ 1 have and ,If n at :,In u Ceniti.nru of Conant dr.elf-insure for Worker's
Co,aprnid
,aliouc n, proved Bre by Section 3700 of the Lanon Cole. Joe li —
re 205 UNDERFLOOR INSULATION
peroluanwol the wad for which thin rermi(is iewed 301 — ROUGH PLUMBING
❑I have and w-0I muimnin Worker',Comrensalinn Imudmce.as required by Section 2 —
378u of me L:rl Code.nrr me pelloloomee of lire work for whin(hie pa,.all i, 301_ TUB 8� O R SHOWER
a.My work Lmr m,rrrana e:rrerrL/nd Pyy�yy r 303 — ROUGH MECHANICRL
Carrier: Policy ION FR O /7 /r'f J'
Olt mICAnGNOPhxrMPru3NplxontWORKERS' 304 — ROUGH ELECTRICRL
COMPENSATION INSURANCE 305 — FRAME
amis section,aced not lie Completed rnhepermit isfor onchundred dollars 306 — HOI_DOWNS
($Rgn m le".)
1 Curdy hart in the performance of me Wolk tar wlheGnrin.... (is l,wed,I 307 — INSULATION
loll nm cmploy nay reran in amancr so a,m INvene subject It life workers 308 — SHEET ROCK
Compen,abon Laws of Carf le ia.Date
Applieann 309 — EXTERIOR LATH
NOTICE 10 APPLICANT:If,after rnaking this Cvreificme of Exemption,you should
Z [...orae xoLjre to,he Worker,Corrrpensadou n n.ofthe Labor Coic,ym fan 310 — TNTERIOR LATH
Q fonhwim,..lily win such pro,ialf,lir this lrennh,hall be then ed!re—laid.r n
Z _o 31.1 - SCRATCH COAT
E• tiCONSTRUCI'[ON[.ENDING AGENCY •
C 1hemby:nm
fice than ere w
:reno, nic.Iendiusenet'
ng for he crion —
rior, 31.3 ROOF NATL
ol'nhe work fur which An,Panrit i,iw...ed(See 3097.Civ.C.)
i c 1<nde,',Name 501 FINAL ELECTRICAL ENERGY
D z lender,Addres, 502 — FINAL PLUMBING ENERGY
U O 1 can y that I have end mi,application and,moo that me above Inlornrmiun i,
W F farta.I agma to...roply wish all lily and eounly ordinualf,and louel rrw,relating 503 — FINAL MECHANICAL ENERGY
O U br building mnstmedon,unJ hereby onion,represemmive,of do,city(a curer urym 504 — FINAL BUILDING ENERGY
he urine-mentioned pml,eny rnr answerer.for,o , -
a IW'elugme ,, arc.indemnify and keep harmie„do,City crCepeninnagainu 505 — FINAL ELECTRICAL
to liuhilift,v,'a gnrenn,cost,and,crena,which aruy in any way acen a again,,said
U 7i City in anrscyucn.a al(ha grmn'mg al,nL"on".
APPLICANT UN"A,1��ull�
DERSTANDS AND WILL COMPLY WD'If ALL NON-POINT Issued by: 506 — GAS TE Sl Date
'GU
50 1, Fill—
Ignairacua D:neDOUS MN'f:R1n1.S UISCLUSDIt1i Re-roofs S�ryg — FINAL MECHANICAL_ofnin,bralding aclopmr sme on handle novvdous mutecial Type of Roof 509 — FINAL GRADE
a,defined by the Cupertino Municipal Cade,Chapter 9.12,and,he Health and Safety
Cade.Sve'nioa 2.553200? �p
El yes 0N All roofs shall be I .p9cted FriIN64'lan�,.[o nNl ae I g installed.
Will the applicamar future building accurate use eyuipmcnl lir devices which If a roof is installc5�i t hoot �r tlYlH�ain�� -ih FpeLk"tiHp gree to remove
cave nvardau,air coal....man,,nodefined by the Bay Arca Air Quality Munagemcel
• District? all new materials for inspection. Applicant understands and will comply with
❑4c, ❑No all non-point source regulations.
Ihme mad rhe havzNou,material,nyuiranems under Chapter 6g5 of rhe
California hathh&Safety Calc Senium 25505.25533 and 25531 1 umler¢mnJ(ha,
kifffichuild!.gdoes me currently have account.nae it is my m,ryrnabiliry nn unify the
[.mum m
or he re,ouranea which rouse be men 11101 It i,suanc,of a Crniticaru of
Oce airy' Signature of Applicant Date
ownnem i,. agent D:r,a All roof coverings to be Class"Br' or better
OFFICE