01020062 CITY OF CUPERTINO - 1
nmLtnne DIVISION' _• PERMIT CONTRACTOR INFORMATION: :
BUILDING ADDRESS: ' - ` 1'p IdIr'NO.
O _,
OWNER'S NAME: - - APPLICATION SUI{DATE
N '
PHONE; IKE _ (1_
SANITARY N . CONTk01-NO.
Q z Z ARCIII'I'IiC111iNGINIZEk. - • " ❑IIILUINC PERMIT INI10
O❑O❑ ❑hDG IILE(T ' PL6
M11H MECII
II
LICENSED CONTRAC I OR S Ill CI ARATION-- a Job Deccri tion
f
Dy en ly lr ,he,I 1. d nl p to )( cm ng ' • p -
I- Ew t tir r.
]g101 rn .� 3 nl n nn :lots
rale,and my Rcen,e � /.
g< si I Ilr d ff t
m
W%< LIC - Cl... a „
io as. Da, Cnt at - INTERIOR REMODEL
t"og I amba,marol mypl shelf heJ mpublic r J:IZ
0�� OWNER HUI IDIk DECLARATION
uu•77 11 by II n J 1 I an,
P11 theContractor's License I the
loll ),rt .(Section 7031.5,R 11 I C I A y 'bl ly
O 1)1 I II urnel,11c,i I I.I IyLulu s 1 Q h
I' I ' 'I q .t 'III' h1 11 tII 6 il,one,en -
t
Itan he isnotionh Ill,p I he( Ilmor,Liwmi,v mv(Chapter 9 Sq. Ft. Floor Arca '1 Valuation -
h1 ten.,t,will,Section 700)of l.. 3lf ths.Ihkas WPmf.,wls Code) `
and I h-''exempt ficefimin ad dan ba fin,the IlegeO esominimn.Any vifelmnon
.i tun r70i11n5r yn ya,adniasrsswl,t'unco,flharipilicatem.evlpettmt> APN Number ,r Ocwpanc'y ypoe
❑I,In nwecwor,ne pal the someone
o eon e i not
c tended or offered
sale(See,
70,t .
wilt do n.,work,and the lemcmm C nal intended d e e Law for sale(see. it,im Required Inspections
Hussars,and Tontitown,Who
ilale:The Cve,Eamon,
,ands Law dce,nm apply re an "
owner of through his ow Who loyees nr ovided tat such mnJ aha Jere such wink himself
o enal his awn employees. bruiidee that such import is sols are not intendednyear or
,,oule or atter v,nnwe.'er.,he nn eying or ht lf,r ofnetn n cold w;mm one year n( 101 FOUNDATION a - •-
colso'enn,me owner-hander will have ale mm�en orprn.mg mal na cid not btrlle or*
"' -
iotprn,en,rpnrposenfsafe.). 102 --. PIERS
own"ol p`lvan, I : ly lean, ml , -. d'. '.tab1 103 UFER .•�,I' .
it.h .I tl j I(S 7044,11 II I'.. C e) C I' '11-x
�r
Lew does 1101 Imply[(I 4a owner oln pc ly who nhld:or- ,protea,n, - 1,04 — REBAR
and who conwet,for such prnt,,v, Midi a aon:roarens)licensed purstmu Lala e
'comm oul,LiocnxLaw. - 105 . — ANCHOR BOLTS
01.,it it,, a der See. _j�da P C for aikoanom ` -1.05 — SEWER &.''WATER
n .
ower -P(A/L� Drum 2 r�p/ DI 202 — UNDERFLOOR PLUMBING
II
'L
A/�(.-N'r�lOik'SLOG)Wp .'r
ON IARATION. -
l•'IlnWcm�nylalnn�n!/nnYJa[pi'nae`'nlr'nr periarr line nnbe rnnnwms Jd�iamrn�,: '203 — UNDERFLOOR MECHANICAL
• 0 I latvc'md will maintain a Ccnifcalm bf Consent to selr.insum for worker's 2204 — UNDERFLOOR FRAME ' ,
Coin pomme, as ovidee for b Section 3700 of the labor Code. for the - 'J e
pcnilrmm�ce of the week for which Itis permit is isn:ed. 205 UNDERFLOOR I'NSULATION',
301 —1 ROUGH PLUMBING
'C1 I Lava anal will mama n'Worker',Compcn,:nion hPuminae,as miumd by Seainn -
3701)of Lha Llmor Corm,le,the parmnnance of Lha wink far wldeh his panne is ,, .302`— TUB &• 'OR SHOWER
Ca TMywimersc p t wt
Iln drory n• arer" 363 .— ROUGH- MECHANICAL 4 >
Cara Policy N
cIa{T FICATION DP EXEMPIION FROM WORKERS' .304 — ROUGH. ELECTR I CAL'-
COMPENSATIONINSURANCE. . .
(This seeenanemmorn
n 'neepleleeifthepo
erntilisfhunJrearednn305 — FRAME
mlxnnne..d - '306 - HOLDOWNS
I roma teat in the Pirfinam n.of be work for is me,permit i,issued,l 307. INSULATION-. .
,hall not employ any person in any manner so as no haeme,uhjeet In,he Workers -
CmnpenadnttlowsnfCalirntnm.Dme 308 — SHEETROCK
Apideum .
NO[ICE TO APPLICANT:If,after making this Ceniliealcof E�:emplim,you sluald - 309 '—:,'EXTERIOR LATH
In rh.1 n1. Ab:Igrhavlarmep.nGrnaa _s SCRATCH COAT
hes ne eh ovet to thew k r pe m p outdo,1 n e I y n
O fnitnmclnplywitt ftp r , na t.l Ila J ked 210 .— INTERIOR ATH
7
,^n f~/� CON Sri
ereRUCr
is,TInN I I lot'he 1It NCY t( 31. 1.
he lh,for elf an Ilea phare s
a � nfttcwmkhlrwhmn,h;a 31,3 ROOF .NAIf_ • , '
C>a Q LCnder's Name permit is issued(See:309],Ci¢CI � "
5 z Lemlar,Address 501. — FINAL 'ELECTRICAL. ENERGX
U O Ireply filed Ihave teadmie"appfeahoutand,.,e )no the aweeinrnnnsoon is 502 — FINAL PLUMBING 'ENERGY
li [r pierce,I a,m,to comply wish all city and county nrdmeneea and ,are laws rel.ing e
O U mlwildingconstrucdnn.andherebyaumorns,oprtsnmtivesofthischy nenterupon 503 —
FINAL MECHANICAL ENERGY
y A. mean', e)g.ee,, mpnymrifymadmpuEeme 504 — FINAL' BUILDING ENERGY
F„ y (p-mentmemeaeety no rYoar"no keep formless the City or Cupenino a%ainst
M lialsfili",judgmems,roles and a'No es wmcn ,a,in any way aecme agam.�said ' 505 — FINAL ELECTRICAL
U z City in consequence of,he granting ofthis permit. _
SOURCE Date AND WILL COMPLY WITH ALL NON.POINT Issued by: 506 — GAS TEST Date
sigll,m�m�,rnppfrant)contmr,ar - ' nano Re-roofs
• nAS.ARDOUSMA'IHRIALSDISCLOSURE507 Pt-ul-1011,10
508 FINAL' MECHANICAL_ -
-Will lhenpphcmlorprime hdldlttgarhlpnlll some mmamlebaramousmiterml 'Type of Roof ' 509 - FTNRL. GRADE
as dofncd by Lha CopenMunicipal unicipal Cole,Chat"'.9,12,and 0c Health and Sena, -
Cade,Section 25532(0)?
0 Ye. ONe - All roofs'shall be�lra ecl-ekl ErJ r�r�an 4t��# Itfif�flrial-being r
'V - _ �+' � g installed.
Will be appfeant orfanare buRJing oamilitt nm egaifterm or device,wmcl; I fa roof is install€14itlmutF�iI4NR6iaiir?hPn Wipdel(IFVpagree to remove
emit Income.,mr conmminants as defined by the Hay Arta Air Quality Management ..
Dlgriertall new mater Is for inspection. Applicant understands and.will comply with
0:e' ON.
all non-p ' ounce -egulations'.a.
` 1 huvc read the hireemous material,s requimmmus under Chapter 6.95 of the ✓
- it be miu Healthitsea n , Cale,have
25505, ,,,3 "'ParY I dnJe dand nand hat
the
if th b ll' 'i mt ndrh e;ucn t Ill., Iiimy rcq blty oily the
¢e„1 t qulrememwhoh matte „r' t ix f -1111i,he of - - -
OcCp' y ` ' - -
Signature of Applicant ,"'Pale
Ow,c- n Mae All roof coverings to be'Class"B" or better'
OFFICE ,