00030167 CITY.OF CUPERTINO PERMrrNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILOINBGADDRFSS: ' {/ /�/�
�/� 1/V'y, /C (/� �. �a/� ,7 • SANITARY NO APPL�TIONSUH��'DATE
OWN'4S F as�c 'sun{//1'I /IJJee. . ' �., i�/W'� �.U�!!� 2,r7 V
Y � N/C CONTROLp
PHUNT •Gide�iadlle f/¢ 9vS5 o '
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�RCIIITELT/EICGIN1iER "' - I BULUING HERMIT INFO -
yey
I- Z LICENSED CONTRACTOR'S DECLARATION `
10-' l hercbr.frrm wt I w Wined aMa prwiaan.ar cn.pmr 9lmnurcame � �.. •' Job Description' .
p H C� with Seuon 0o00)ofprvmm�3afthc Buunen utl Prafenian+C ntl myliannrs �> '
<x Li cnls f e
C and _.�._g7 l Lic6 Y17/1
i53 a w Data h a aa
O DECL .
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1 understand mY plans shall W used u padhe records -
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Licensed!Professional
_ OWNER-BUILDER DECLARATION
C Z_a 1 hereby aRnn than 1 airs asenp,from the Contractor'.License Lew for the
C following reason Oicamn 7031 3,Bovnae and Rorcui...Code Any city or county
w6 j:e which repulses.permn to runabout,slier,Improrr.demnh,h.or ir,wir any structure 3q. FL Floor Area ddd Valuation-
but ..
iro to its i licensed p alvo rtgotrts pre vision m tla,forsuch pemdt m ce s Law(Charter ���
he issicundpunuaonores the wilcnf w Conharnfa Licrnsalaw statertt9 - '
(cam a is axe wlN Secdon 81007 of basis n]afthe Busmen andon. Any violence a of --
.wt he¢exam t wrtfrom and w buss for the alleged exemption. An labors of bar Occupancy Type,
p g p r.ro P Y YP
Seuon dent by any applicant rs 4 pcmdt subjects w applicant ..ivil peiulsY of OO ' t - -'
i more Nan Rve hundred dollar.fS3IX11 - .� '1 '
❑Luowner of the propeny,mmy cmplayw wise wagesu Neh wlc compcnuuon. Required Inspections
will do able work.anitdu, urcu netunnndedoroffered far.1.(S..Tka,Beat..
and Rofesuou Cods:The Contractor's lice.law does saw apply t.an owner a '
propcny who builds or improves wren.,and who does such work himulf or duough s „
his own employees,provided that such impmvennnu art no intnnded or offered for
ale lLhoweveew Wtldmgdrimpovcmcmhwld wiNin one yearn(compled.o,w
owntt-Wilder will hats die Warden of pmvGB that he did not build or improve for Pur-
Pon ot.we.) V '
❑h u owntt of Ne PropenY,am adus.vely convnnng wIN I¢enuM conuamssn ro , ,
construct des not apply an wnerof nosProfession.Code:) pro Conuvmoland y
came Law cts for not apply je ts owner of progeny who builds or imttuvn wrcon,and
who contracts far such projects with econtratMs)1¢eud pursuntmshe Covbeno/s
Licenra law
❑lam exemPteMerSe. - ,B&PCfor Nn won '
Owner 'Dam -
WOROWS COMPENSATION DECLARATION
ertby a i_under p' of perjury oue of w(ollgvm6 doel"nons
endwillmemtains CerilR.a ofconlmttoulgmsumforWorker'.Compen-
wo'on, provided for by Seuon 3]00 of the Labor Cade,for the pert.munce of the
a which Nu permit Is issued
.have and will mountain Warkds Compensation Insurance,as mquurd by Section "
37(0of the labor Cade,for the performantt of the work for which this permit is hawed. -
MyWa'kee C m hit Incur curia and Policy nu r'��
Comer. ! Policy No, I'� ltgll �
T�PTIINN FROM WORKER _ 1I 9 us _ 1 1 L9
COMPENSATION INSURANCE a..J•� lJ 1
V
' (Thrs secdnn need not be<nmPletM dthc PCmunsforone hurwrN ddlen(3100) in
'or leu.l '
Icenify whit the rt eof Ne wink for hrch the uuuued,lshwl
nmemplorsnypenon Ian uew Yh a Hen'Compen-
sabon Law.of Cehfo
Applicant
NOTICG TO APPL this Cmificnc of Excmpton,you mould
beome tablet low W 1.Compenun in pro nuc ns of the LaWr Code,you must
fonhwith comply with such provi.m Nis permit shall b<d«med raveled " \f�, pp ® ,
'CONSTRUCfI 0N LENDING AGENCY
O,Q I hertbywhnn NU Nam is a (See 3097, agency f.nhe perfomwme of , a
y Le work for which this pcmut is issued(Sec.3091,Civ.CJ.
F. Lendre.NSr• _ -
.ai > I<Mer.Addrc••
tag i cmity w11 have read du apPhcan.n end sum wt the eats m(ontunon 1. - - - -
(fSS.. I agree n,comply wM ell mty nti comma atnteo f and sum law,rclumg ro - - .t
U Z
building ro.vbucd.h,and hereby authentic rconea Ves of thn city to enmrup.n the
U 0 above-memi.ned progeny for impeb.n Wrpmes .. � .
Otit• (WC)eye In r.tr,Indemnifyandtech any anwCityrue at.,aagain r
U hebthnu..boCoffl,creane,apmnawMCn may in any way oases agwut aid city
inconsequence of the gruung of thrs permit, • - '
[� Qr A PPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT -
V z SOURCE:RF.GUTATIONS.
SignnureofAppllienticonuumr: �. .r" -. .t Due c �1V but-1,-C,
RAZARDOUS MATERIALS OISCLOSIJU� i
W,Ii o.Mhugior W,u mWldmga�upantanrcorhandlcha.vusmat al Re-roof% v
as defined by the Captive.Mummpe�C aptef 9 12, Ne Heil and Safcty s
code,Section 25532(idl '11 '„'2Q ',\ '�, TI pe of Roof ' •.
eca All roofs shall be inspected prior to an roofing material being
Will thc epPhcut r(ut re pant un cgmpmem or devices which y
emit heurdous ar contvnmanu as de ra1by Ne Bay Arta Ali Quality Muiugemenl installed. If a roof is mstalled without first obtaining an inspection
E1 la TTpree to remove all new materials for inspection. Applicant
U Ves' 'o
ay.� un erstands and will comply with all non point source regulations.
lhave read the assrd vtumnw utmmenu under Chepmr693 of the Cali- �.
ford a Heal fe C ,2553]arM 25530.I uMenurw the If w r -
huilthng a cu d esmnunt tin.my mspunsiWNt onddy ..pant ,
' old s sal stW to wuaus C< icue a( ry '
.Signature of Applicant . ". Date '
Owrar D 1 -
+ ' - All roof coverings to be Class"B"or better
OFFICE .i. • -
r
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
4 BUILDING PERMIT INVOICE OPERATOR: christya
Sec: Twp: Rng: Sub: Blk: Lot:3262OOO9.00
INVOICE DATE... ...: 03/27/2000
REFERENCE ID # ... : 00030167
SITE ADDRESS ..... : 10100 ADRIANA AV
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: STELLMACHER RICK V AND PAMELA
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-1126
CONTRACTOR .......: LIC #
COMPANY ..........:
ADDRESS .. . .......:
CITY/STATE/ZIP .... ,
TELEPHONE ...... ..:
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -----------
BPSEWER P 19.98 0.00 19.98
BUSLIC P 90.00 0.00 90.00
PPERMITFEE P 35.52 0.00 35.52
--------- ------------ -----------
145.50 0.00 145.50
ID ...... ..DESCRIPTION. = ........... VOICE ID ......=DESCRIPTION
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 302 TUB & OR SHOWER
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
MAR 2 7 2000 .I