01030158 CITY OF CUPERTINO - - •q9" ' a —
BUU.DINC DIVISION PERMIT; CONTRACTOR INFOkMATION:u�
IIIiLDINOADDRESS: , PERMIT NO -
20555 ACADIA CT Oi 171_ia1 �,A. _
OWNER'S NAME - ASPLICA'1'ION SUB DAM '
HFI F111 POT AZ/:+el/rfAOf1 _
f IIHONF.: SANITARY NO CONTROL NO. '
ANCHITIiCr/F:NOINraiR _ RUILDING PERMIT INTO
LICENSED CONTRACTOR'S DECLARATION
Z". I ne;eh;alum dl.n 1 ma rcce,ee mmar I Cb, la,a Job Description
> pngl„etn,, P rdan,nrene 1
-u� wnh Saaam ANNA rIDivmmo3nflhc Bucencn,enJ Pndcisnmc Calc.and my hrenre ,
-ea xi 6 Lmerse Class enJ rpe<b Lec.a
puU
Date comracmr CHANGE EXISTING LAUNDRY ROOM .TO, BATHROI
r Be o`F' •ARCUfrecr'S DI:CLARAI[ON CHANGE CLOSET' ROOM 1'O `LAUNDRY ROOM.
I understand my plans dia11 be used a,public recnNs i
T
Licensed Ie wunuel
o 'nde OWNIant11Ianipt,from he RAracto ' FINALED
1 hereby asect that I any cmmpe s an the Crsions C s :Any c Law for the
C Z< vvhurh
following reams section 7031.5.Ruvne,.end improve,d arm Code:Any my or count)
xhsh reyuercr a penni,m cnnama,alms,mlprrve.AemnlnM1,ur repair any,wcwn
u�F1, Inunm n, tanre,.J,n;cynu e,;tic nppheuntfor such lui miuu We a>;encd xnncmcre
°' m ,hmhe,licemeo PUnumnmme mf mmn nl the the B.,irw,,andwhralCh Co,10 PI I�ea L 1• Ay tJi - -
• fenmmhenslexmptthenmm�nntheb a%t% artheaBexapronAnbnacrJel Sy. FL Floor Area Valuation' .
a that he I. 11 5 b mn,mp one rnr Waco far the alleged s te ceempurn Any violation -
.1manon]nanlive ado'ddnntar$510) l,ublcc„,heuPPl¢nm,oucnllPcnalty NG -
olnmentrc,han R,r nnnared anu:e�asxn APN Number - BUILD Occupf 0' �e ..
c
\L as otheeror,an! the army employm,wM wages a„heinol<le se,compensation, ..•
wet a the work,and the ode the et nn,inter,L.rt ol�Lots doe,ale.,,l ]613,
Ruann,and Pny Wiinn,Qnlcc he Cmurtincee Ltremc Law Jms noT•epk I.m m, ulred Inspections y,
r of pmpeny Who nmWc nnmpmee,at such improvements who tits re n work turfed or .'J2656f1120.
or mrouyh h,rx n however.t Prondin that such vin mn is%ol :tie not one,year or
nflrr<le tin sale . ..mill r,the hmWin6 a improvement e,col,within one,y<.d or
mmleurnt the owneMmlJCi well have life bu,Jrn nl Pnnmg,h.n he and one huJd or %101: ,FOUNDATION
.Improve tar pup,om of<ale.l �'
102 - PIERS
❑Lasowner of the Pmpenl', 4,exclusively [prof usi with licensed Connctry - t '
' ,mwc,the project IScc ]IUal B,anea nnA erme„iom Cal'n The Connector. _ 3,r
- ' i�ner,<L:mam,nma 1 ['I all , 11onada.aem ;Hereon, 1.@� LIFER
Pp Y Perry x prover
and his cmnrens fLr such Pro)ttIC with a<rdtmnrnr)b<em<d Prr,nan,m.,ne 104 - REBRR .
cnntmrmrt License Law. ,
`,olamefxn�l �, B&liC far m;,ar...a 105 - ANCHOR BOLTS
rd°_ Vii' Dnte 2 /111111. 106' - SEWER & WATER'
RONKER'S COMPENSKIION ION ,
I.hnenyetrr;n andetpnnll,of Penmy tic m;her;,unwiu,Jenara;inn;: 202 • UNDERFLOOR PLUMBING
❑ l have and will maintain a Cemrcal,or Consent to self-m,nr<ro.r Work.er, 203 - UNDERFLOOR 'MECHAN I CAL
Compensation, as "ovided for by Section 37M of the Labor Code. for me 204:,- UNDERFLOOR FRAME
prm,nn.etie,:onn<wtlk lorwmrll his pet,Ie 205" =- UNDERFLOOR INSULATTON
❑W have
if ati mmme, o, her.Ctmlmor,ofnln,amme,r reynrcenySttttn" ` 301 - ROUGH PLUMB,SdUG
3Ju'of me IaMm Cale,for he Perromanee of cr wort far taro ar perms Ic
it,ace.MY wrrAer,enenPelnatmn mcomna rimer e,w Prlery mnmetat<: - 302 - TUB, & -OR SHOWER ~.No Cart;= CEMIFICA'1'ION OFEXEN117IONIROMWORKERS' 303 ROUGH MECHANICAL '
COMPENSATION INSURANCE 304 — ROUGH ELECTRICAL.
,Th Is.en..in nee,not be ermplaod d the Peon ea for one hvndrc,Jull.m' '
IslIXllnt l<,>, '305' FRAME '
I a,Inr that m roe pem,nmanic of not wort to whtch me,Perms is tamd.1 306 'r HOLDOWNS
,hau no,nnploy any pm,,,a m any counter...a,m beenme,able,, ,, he Water: 307 - INSULATION
' I
Co mpemauon L ws ur CaLfnmia.Date "
Applicant NOTICE''O APPLICANT It,ahnamy,hn Cenrcam of Bxcmpn,you should 308 SHEETROCN
Z Oneetme,0,Ieellnlhr worker,C.,e.,penalt owe„a,novel-al coae'youuas' ?,@g. - EXTERIOR LATH
forthwith comply raim inch pme.vont.,.his perms shall le deemW re,okea1, _
?
(~ r�•e CONSTRUCTION LENDING AGENCY 310 - INTERIOR LATH
1n„rny:,meeenh.nn,tie;,aannarordbn Jena;;,s aerney meat 1,,,tmame ' SCRATCH CORT�
C > of,icewort lot whha11n,petame,;standIS.•eNN7,Clv.C.)- ,. 311:'-'
a c •Lenders Name 313 - ROOF NAIL
,7 z Lender,Address
C 1ernilrwa ln,avercad this apphemun:md,mmd,a fin,it.emimmnamn,, 501, . - FINAL ELECTRICAL ENERGY
Fcones.1 agree If comply with all city and cnumy mduance,and imta law,relining 502 - FINAL PLUMBING •ENERGY
0 („) mbmldmg contiue..rn.and bercny nmbmiir,aprcxn,mnex oflh;s nrym enteruPon
heehoo omennrnedpm,rynmmP<cuonpurpse•.- 503, = FINAL MECHANICAL ,ENERGY.
ry W,,aeree,o al.,orde;;;;I;I,and k,v,hurmlc,n ehe Co,of Cnpereinu agues„ ,
y IiabJeucc,rudgmenn, and mperoe,xhah may in any wey.nccruc agma,I said 504 - FINAL BUILDING ENERGY
U rzn Cnyma,mequea I gminmgof ipermn
souRCA L 1. ANDS/#D WILLCOMPLYWinALLNON-.pGINT Issued by: 505 - FINAL ELECTRICALDute �•
'SiVE( Qlfp1 crnvcrmranm Data Re-roofs _
HAZARDOUS MATERIALS DISCLOSURE 507 FINAL PLUMBING
Will me npphcam or fi.I budding I.nopvn now m har,lo ha,arlme,mnenal Type of Roof
a,JerneJ M1y,he Cup<rlenr h npol code,charnel')12,amt rnr Iiralm and Safe,, 508 — FINAL MECHANICAL
Cale,sccton 2553260] �r�C
Ore, No All,roofs shall bb75spectQP0ItU.fill Yt & material being installed.
Wilms'apphranlorNu;ehadalllener,IPan„I, cym.lt<Il(If dr., 1hub If-a roof is installlowifhcfutlIh0lobtR i VAAlk9ection, I agree toremove
ems hvanlous air nmtamma JerneJ M1y the Be,Arca Aer V,Ill�ItY h1anagnnem
Dlmnn] all new materiafAV&inpFcdNPlAp9WR1t.1QerkJkM5id will comply with
0 1es all non-point source regulations.
•` 1 have,r it mNtut mamrmb rcyuircntelna under Chapmrfi95 of the
California He f yCode,Secure,23505,2553)and 25534.1 undenmrdmm
,(,he build” rtemly have mnam, he,,,i,my re,rymandnym citify the '
Wean n , re,n�temedn whech mils tie eon Pntem et.uanm rr a eenerc:ne of .
G, Date
3��L��/ Signature of Applicant _ � �
nr amhnme, em m
/— All roof coverings to be Class "B”or better ,
OFFICE
- _�