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CITY OF CUPERTINO
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CONTRACTOR:IN ° RM
-
TION:
BUILDING DIVISION PERMIT
If Offs B EY BLD 6454
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PERMITNO2a60150
.140tIWIC GAS AND ELECTRIC CO
APPLICATJ9r6t/ffP92002
HONE:
SANITARY NO. CONTROL NO.
ARCHTTECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECTPLUMB M[CH
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LICENSED CONTRACTOR'S DECLARATION
I hereby gloom that l am licensed under provisions of Chapter 9(commencing
STRUCTURAL UPAWN4MM AD COMPLIANCE
i with Section 700(b of Division 3 of the Business and Promenons Code, and my license is
9 in fall force and affect.
TENANT IMPROVEMENT
c License Class Lic.0
Date Contractor
ARCHITECTS DECLARATION
A
^_
1 understood my plans shall W used as public menods
8 7
Licensed Professional//IvI�
OWNER -BUILDER fr DECLARATION
1 hereby maso affirm than 11. eaemnt from the Contractor's Co License Law for the
following mann. (Section 71onsur Business and in Coale: Any tiny moony
Which isms a pmmit it) con v improve. de any swmum
demolish, s
alter, improve, demolish.
$971880
its the fie a sig
nttic,o the lhevisio sof forsuCh the Contrarmiuo0anic LawJ anammcm
' that hnitscensed pursuant
(commesccgwithSfction7 h)
Sq. Ft. Floor Area
Valuation
ar ofDiviomolthcConuiness ndProfIaonsCodmf9
on 3for of Business ns Code) of
(commencingwiththereirion
(cat
31603
045.00
and
Nal he is compo thertmm end doe baso for Ne alleged exemption. Any violation of
he is the basicme ase eged i. Any
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
not mon than five hundred dollars ($900).
101
— FOUNDATION
rl I, as mvner of the properly, or my employees with wages as their selc compensation.
102
- IRS
Required Inspections
will do the woh, and due socmrt is not intended or offered for We (Sec. 7044, Business
and Professions Code: The Contractors License Law dna not apply to an Owner of
103
— UFER
properly who builds or improves thereon, and who does such work himself or through his
own employers, provided that such impninments arcnm intended oroRcmd for rade. If.
104
— REBAR
howewn the Wilding or improvement is sold within one year of completion, the Owner.
105
— ANCHOR BOLTS
Wilder will have the burden of proving that he did not Wild or improve for purpose of
ale.
106
- SEWER & WATER
ter of the properl,, am exclusively contracting with licensed contractors to
202
- UNDERFLOOR PLUMBING
o Irvcl the project (See 700, Business and Professions Code:) The Contractor" Li.
cense law does not apply to an owner of property who Wilds or improves thereon.and,
203
— UNDERFLOOR MECHANICAL
who contracts for such projects with a contracumbn licensed pursuant to the Conlremor's
204
- UNDERFLOOR FRAME
Liceuse law.
p lam cx Pl sander sec. ,B&PC for this noon
205
- UNDERFLOOR 'INSULATION
Dale Z
301
- ROUGH PLUMBING
JO CE'SCO •NSATIONEC
DLARATIO
302
- TUB & OR SHOWER
I herebyafrvmnnder penullynf pefjuryone or the folk.luanions:
303
— ROUGH MECHANICAL
❑]have and will maintain a Certificate of Consentmself-haum for Worker'scompen.
304
— ROUGH ELECTRICALsalion,
a provided for by Section 3700 of the labor Code, for the performance of the
work for which this pcfmit is issued.
30.55
— FRAME
❑ 1 hast and will maintain Worker's Compensation laurance, as required by Section
306
- HOLDOWNS
3700 of the labor Code, for the performance of Ne woh for which Nis permit is issued.
My workers Compensation Insurance carrier and Policy number art:
307
— INSULATION
Carnet: Policy No.:
308
- SHEETROCK
WORKERS'
CERTIFICCOMPENSATION
309
— EXTERIOR LATH
INSURANCE
( hissectiou neednol becompleedilthepmmilfsp)ronchundmddnlim(glM)
310
— INTERIOR LATH
of leas.)
311
- SCRATCH COAT
I certify that Indic perfrylpence or the work or which this permit is issued, 1 shall nOl
313
- ROOF NAIL
emplouf Cali! Iglisirnal�crsgps tt'vac suhjem hinso ^ rs: C�
L
501
—FINAL ELECTRICAL ENERGY
PPI at N
N�ICET�i PPL1�: If, stir makin is Cenificate of Exemption, you should
502
- FINAL PLUMBING ENERGY
come sub' ct to the Worker's Compensation pruvisinns nr the labor Code, you must
503
- FINAL MECHANI CAL ENERGY
forthwith comply with such provisions or this KOWL shall N deemed mtolard.
504
— FINAL BUILDING ENERGY
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a consoction lending agency for the performance of
505
- FINAL ELECTRICAL
' the Work for which this permit is issued see. 3097, Civ. C.)
Lender's Namc
Namess
506
507
- GAS TEST
- FINAL PLUMBING
lander':
I cenify Nat 1 nave read this application and state that the above infneentiun is
508
- FINAL MECHANICAL
' COMCL 1 agree to comply with all city and county ordinances and some laws minting to
5
FINAL GRADE
building commotion, and hereby amhimire represenmtives of Nis city to truer upon the
above- mentioned prepruy for inspectionpurposes.
10
FINAC PLANNI G
(We) agree m save, indemnify and keep hafmuss the City of Cupertino against
I liabilities, judgments, costs and expenses which may in ay way same against said City
5
F N U LI WORKS �/g N
' in comaquence of Ne granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL NON -POINT
Issued by:
i/
Date
SOURCE GULAT N
Re -roofs
ill O �IOZ
O App Colvacmf Date
HAZARDOUS MATERIALS DISCLOSURE I
Type of Roof
Will applicam or future building occupant smm or handle havmdmis mamri d
defined by thCupeninn Municipal Code, Chapter 9.12, and the Health and Safety
"hi"
e, semina zss3z(a)'I
All roofs shall
be inspected prior to any roofing material being installed.❑Yes
lit".
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding Occupant use equipment or devices which
emit hazardous air contaminants as defined by the Day Area Air Quality Management
all new materials
for inspection.
District?
❑Ycs '9 No
HE mad dm W raNnus materials requirements untkr Chapmrfi.YS of the Califon
ria Health&&army Co.ScNons25315,25533od25534.1undentandthanifthe Wilding
does not currently haw a mound, than it is my responsibility to notify the Occupant of the
mqui mswhic rens Ipoor toLss cenracerlintamur tupmty.
Signature of Applicant Date
Figs to be Class "B" or better
ser or amt nvcd agent Date