01030065 CITYOFCUPERTINO. r;
nun:DING DIVISION . - CONTRACT OR',1NFORMATION
,PERMIT 3ry.,
BUILDING ADDR I
21.42E 'AMULET, DR Aro A A FURNACE .CQhI PERMIT
no, 01030065 '
OWNER'S NAME:+ ' APPLICATION SUB DATE
SLRVIK SUSAN S AND ROB RT ,F_ 1712 STONE' AVE ' 03/13/22001
PHONE: - • SANITARY NO. CONTROL NO.
(408)293-4717 .
.. 00 ARCIII'I EC'IYENGINEER: 1• - ., BUILDING PERMIT INFO
6 u BLDG ELECT ,PLUMP MF
HF�dJ-
Z O H Z - .. ,LICENSED CON FRACIOR S DI CI ARATION - "", •• .lob Description
O Z'�G .. I M1c'cby atTnn thin t o f `d f p f Chapter 9(un
nmr ng. • _ - t
F'3k� S i 71gU)rt DI °lof the Bn dP
W . ` Z # i REMOVE •'OLD DUCTS R ' INSTALL NEW. ADD,/R--
NSD
L ECLA lO DUCT I N HALL. :
xe+l:u
A CHI rLCs .hire
r
'CS�O �1 undersmnJ ally plana.hall he urecolLow o'edilodc"'i ,it
tls
me�
OWNER-BUILDER DECLARATION /
I b ld ee m flad l n'[ IM1 C I I I'c I f or
♦_�j< •fog iSic,do.70215 Nosiness and P Code A Y 1Y 0 ° -
,'SySG pr j t, n' 'Iw rl .......I
yj3 lletrt t I. q IapplicantI noon', I a . ,(Chapter
temem
'math I e. d p I t d p t o tl n1 I e L ee I (Ch 6dr) _ S Ft.'Floor Area -
O.o g thS t 7rair fhe 3 [d p 'ne JP f C«le) , - Q' - ..
nr lh tl lend lhecfr mond the basisf II .IlrgWr pl AY,Perlin - `
ofs i 70315byfinsPPIdant.. p 1 n7 cisIbeuppl II itpenAlY - p S31M5
nor r thin,nveh�wreadmm�($soo)_ APNNumber�' - - � .,Occu anc -
pIas otstraidthepn,penXnr any ennnhy with gesaxlh '' I Rensal nn,
willd.IM1 k 1 the xfracture is hot fI d 1 B d for side(Sec 7090
Bud re::a d profess ons Code.The Cott e ense Law does not apply t n - 3264304`.ReQIFI?ed Inspections .. '
ownrairf,orner,Who buddynr i mpn,vits tl aid who dnea etch work lin.elf e
or through his own ennployces.provided that such inTrnvemcnle secret intended or "
offered ler yule.If.however,the building or itnple,emenl is sold within one year of -
clanpsholl, he nwr"brilder ww line the baleen of Wovtnglhtn he did not build or 204 UNDERFLOOR FRAME ,
„reed fie'rifnew nr.gle.).-
❑ c ' 301 —-ROUGH PLUMBING
i orlm p pear ela oan ,,
Fidler IS 7044 Business and P ,osr,C I Oi .Sno,c303 ROUGH"MECHANIC
AL
License Law does a., l p1, I p pr ry h holds p .Ih�n
and whocontrols r projects win r ntraelorrs) Icenxed parsaanl Io Ine 304 — ROI_IGhI ELFCTR].'CAI.. -
nICar'llors.Lten,eL,w. 505 '— .FINAL_ ELECTRICAL.
❑1 am cae, ander Sec. ,B'k P C rnrthis rensan .. ,
Owner Date 507 — FINAL -PLUMBING .
WORKER'S COMPENSATION DECLARATION 508 — FINAL MECHANICAL-; -
Fhrrehyarrntt trader fertile of peia:y ane ofthe following dictatorial _ 514 — FINAL PUBLIC' WORKS ,-
N {❑ I have and will mainmio a Conifeale of Consent to yell-irotee for Worker's
A Conn,ehlition, ue provided for Ay Seelinn 9700 of the Lail Cade, for the
performunce of the work far which this,clean Is Issued."
AGhave and will an olein Worker',Cen,pemmanie n Insurance,as required by Section .Y
O of the Labor Cele,for the adorn ence of the work for which this perm'u is ,
d M W ker'.i C ai n In armee carrier,nd Policy' b - _
Cor e Ufi Pid cy No
Chat IP CATION OF EXEMPTION P O ORKERS'
COMPENSATION INSURANCE. ° s • .r
(This section need all he comple cd if Ne permit Is br rnr hundred dollars -
($100)or less.)
I eternity Wm In do,performance of[lie work for which nils pertmt is issued,1 '- u
. .hall not cmpioy any person in any manna sr as ,,become subiaer to the Workers'
Compensai_irn Lnws of Cold fin.Dole - 6
Applicant -
' N(l..to TO APPLICANT If, ft per gt1' o nr t of,Laborimlyo oni uld " ' -
z hueofficermthe eira Workers C p n-I p Ithr Labor Code you tilt
forthwith Ilywlb oichlro,isifan,or pernitshWl or tire awlmwked. . _ • '
Ei . CONSTRUC310N LLNDING AGENCY '
T hereby aFlirin that s onst i plead ng agency arthe pedi mane-
W Lae work for which lh' pe t ssucd(S 5097,Civ.C) ° - - - -
Lender'e Na re z Lender's Address-
•' V'Q 1 cerfily tkt I have tired Los applicefron andstatethat tire h 'anoortandion is - - °
.� [r cerre t.I o'her to onap],wid,rd city had round, 'i anc l It,.laws rel ting
QCJ mbltfing eantlactican,and hrebymlhor ncscuntiveenl lhs chy to mneralmn -
�1 theanove-mentioned proamy ra,ns,ection purposes.
�`y 1
(We)llad 'fy add keep h I.:the City itI'C I ri 6 net -
.rti VJ liabilities,hoLdriontis,cost, t W espenw,which ay In arly Y e abs ns1 Id
6,1 City gtrna.nrthe bmung ofthis prn't.
APP (CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Datc'
ell'
EGULATIO s _ issued b
sl .,atm lApplicna a raemr 'D.m- Re-roofs , -
FIAZARUOI',MAI I RIALS DISCI.OS URE '-
-
Will the appieanl there,b ld' g necnnsnl store or handle haze J,ua material Type Of OOf ,
ax del d by the Cupertino M 'p I Code,Chapter 9 12 and tire Ficullh and Safety - '
" Cod S i 25532nd - '
°r El N Alk hall'be'inspec_ted prior to any roofing materi • g Inst d Will i" 1 Pi not f hu Id' b pr r equil I d swex which cin "If a roof 1S Ut first obtainin an coon,1 agree t0 remove
anith d fin v to defined by h Bay Arend Q ally Managenen g g _
District all n materia: for inspection. [derstands and will comply with
❑Y. , =oxo + a on-point ' urceregulations ' - _
I h mad the d : I-lids requirand,nd Chopl x6.95 of lla'
California Hdlth&Safety Code,S tis 2550525533 and 255341 anderitand Ilial
if
�Ba,bond,.,does not coram ly hilae a school, It i,ts thy tespensibality to fairly the' '"
euport or the requirements whichithexl be met print Ir issuance of a Cemill of
//r✓9�� //I/Z����j','�� n g Sign re of Applicant '� ; Date _
p�PF Ytd�en1 '• v. '/I .%3iQ - y. n
�. _
•All roof,coverings to,be Class;`B or better
OFFICE t