01050182 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10804 BROMAELL DR CONDITIONED RIR 01050162
OWNER'S NAME: APPLICATION SUB DA'I'li
4 B RILMN AVE 05/25/2001
• PHONE SANITARY NO. CONTROL NO.
MXZ ARCIIITECTIENGINEER: BUILDING PERMIT INFO
W BLDG ZILECT PLUMB MECH
t?<ac
LICENSED CONTRACTOR'S DFCLARA'IION
zs�< 1heren OhrnllealmdGcer.edamde. rcnareto Job Descri tion
y in pnwininns o P (commencing p
FIn with Seel iT000)of Division 3nf the Bteinesrund Profs„irm Coda and my license
or
�� 80000' BTU FURNRCE CHANGEOUT.
oaU D,,trn_%V_r_' utnraslm_ 3 , TON AC RDD ON ELECTRICAL CIRCUIT.
3s, ARCHI'1'fiCr sal ION r
C�{. ? 1 understand my Plane shall be used
as pu cords -
or
6 p Licensed I'mfmsinnal re
%ea OWNER-BUILDER DECLARATION ,
W—w 1 hachy of fin loo 1 am,x1,11,1 front be Comemtur's Li,cow Law for the
? following reason.(Section 7031.5.Business and Professions Code:Any city orcerany
$d O xhicb requite,a perms,Ia.room,,,idler,improve.dentoli,n,or repair any n omm re
i3= ,mor u,its issuance,at leynirtstheappresen htr.amh pension file:,signed statement
hat he is licensed formation to the provisions of the Contraccurev License Law(Cramer 9 Sq. Ft. Floor Area Valuation
(,stromatin,with Section]WO)of Division 3 of the It me,,and Ponessioa Code)
or Nal he is exempl therefrom and Inc basis for the alleged exemption,Any violation
of section 711315 by any applicant I'or a permit.subjects Ne applicant to a civil penalty
ofcolnnramntfoc tnndreddollars(as(m). APN Number Oecupan
❑I,as owner of We property.maty mnployees with wages ns theirxule rompco,olion,
will do IM work,and the slecone is not intended or",feria for sale(Sec.70w4,
Business and Pmfesinms ends:The Contractor.License Law dttm not apply to an - 3692103e'�.fired Inspections -
owr,,of property Who build,nr improves thereon,and es who dosuch work himself
rr through his own emphi,ce,provided that such improvements are mol mended or
nutted for sale.It:howevver,the building or improvement is sold within one year of
umpmtion,the ownenbuilder will have tem
e naat of proving Nal Ire did ten htdld ur -301 — ROUGH. PLUMBING
improve Ibr purpose of alaJ.
❑1,n,owner of he poverty.am esch„ively momruting won rne,nad rjuna,les 303 — ROUGH MECHANICAL=r
Lnstruct the pmjcct(see.,Iwo,Business and Professions Coda:)The Cos ntra 304 — ROUGH ELECTRICAL
icense Law does na apply ,,an owner of property who bunco or itnprnves Ihctern.
and who momous fm such projecu with a aoatmmmes)licensed vm.,m.....me 505' — FINAL ELECTRICAL
Co,nmcmr'a License Law. r
❑I am exempt under Ser. _ ,H m P C un this reason -507 — FINAL PLUMBING
owner Este �0 ��NAL MECHANICAL
WORKER'S COMPENSATION DECLAIIAI ION
I hu cby affirm r dcr penalty of perjury one of the billowing Jeclamtiom:
El I have ;rod will rerecho it Cenilicate of Comem to wir.inmm for Workers. APR 12 O 2002
Corpcnsmion, as poordal for by section 3700 oI Inc Lrbm Crwe, for the
performance of the work for which this permit is issued.
❑I have and will maintain Worker's Compensolion livomance,m required by Scclinit BUILDING of the IaMtr Calc,for the performance of the work for ishich this permit is
,.meds My Worker's Congzmatmn Insurance currier and policy number are
nlar:_�(Ae",O�JH l Rr lity Na: LVe197Sr72%
G17RI'IFICATION OF FXEMPfION FROM WORKEiR3'
COMPENSATION INSURANCE
(Thin section mored not be emttple¢d if the i,rte omm hundred dollars .
o lm))or leap.)
1 certify that in the performance of he work I'or which this Fernot is issued I
'shad not eutploy any petwn in any manner so as to become subject to the WbrkeK
Con psrmmion Laws ntCalifnmiu.Date
Applicant
NOTICE TO AI'PI.ICAN'T:❑:ulhs-making this Cenificwe of Exemption,you should
Q pbecome subject the worker's Compensation provisions or the Lahor ,Code,you roil
m li,nhwilh amtPly with such provisiods or this permit shall he Jemmed mvnkesl.
z_
E-, ^ CONSem is rc0NLENDING AGI?get
hereby which'Jr.'Mete iss enm,BaSee lending agemty li,nhe performance
or hit work fm which This roil is isnucJ(Sec 1097,Civ.CJ
a z Londes Name
� Z Lard,,, -
1 cenil'y that I have read This application and state That the above information is
c
[r rnnl.l agree to comply with all city and courtly ordinance,vita gate laws relating
C V
to building mnsmtmim,and herehy authorise reptescnmoves oftnis city in encer upon ”
Sys [r7 me a vive-mentfonal property for inspection purposes.
(We)agree ms;rvt.indemnify and keep bar less the Chyet Cupertino ugainm ,
h liabilities,judgments,costs and expense,which Inay in any way Beane against said
U Z City in ransequenea of the os min,calili,permit.
APPLICAM1 'UNDERSTANDS ANILLOMPLY WITH ALL N,Op�POI
souecE �;m.AnoN~G / 5� IssuedbY Date —•V
signs In"Bramticontmmar D;,w - Re-roofs
HALMtDOUS MATERIALS DISCLOSURE
Will'he appnchm m fawn hailding rwama,v stem m nattmt na awns,Inatedal Type of Ro
to de urvi by the Cover ino Municipal Code,chapter 9.12,and the Health and safety -
Code.SmOon 25532(;0!
13 Yes
o”" All roofs shall be inspected prior to any roofing material being installed.
Wm the 1111)]call or fulme but ting mcnpaml ase equipment nr devise,which If a roof is installed without first obtainin an ins ection, 1 a ree to remove
m
emit hanlrm air comaminatn,as delined by the Bay Area A it Qual sty Managers,on g P g
Di-,Rte'"
0Y" No PP
all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
I have read the haiumnm mmcrial,requirement,under Chapter 6.95 of the
Canh,mia 14ee11h k Safety Code,Sections 35505.25533 end 25534.1 mWonwml That `
it the building Joss not currently home a tenant,that it k soy respomilin itym ramify the
occuptmt nI Ibc requinenenls which nnnl net prior m is,uonca of a Cenificmm of "
Occupancy -
�/ Signature of Applicant Date
owner aroundaxon' /Dart All roof coverings to be Class "B" or better _
OFFICE
CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10804 BROMAELL DR CONDITIONED RIR 01050162
OWNER'S NAME: APPLICATION SUB DA'I'li
4 B RILMN AVE 05/25/2001
• PHONE SANITARY NO. CONTROL NO.
MXZ ARCIIITECTIENGINEER: BUILDING PERMIT INFO
W BLDG ZILECT PLUMB MECH
t?<ac
LICENSED CONTRACTOR'S DFCLARA'IION
zs�< 1heren OhrnllealmdGcer.edamde. rcnareto Job Descri tion
y in pnwininns o P (commencing p
FIn with Seel iT000)of Division 3nf the Bteinesrund Profs„irm Coda and my license
or
�� 80000' BTU FURNRCE CHANGEOUT.
oaU D,,trn_%V_r_' utnraslm_ 3 , TON AC RDD ON ELECTRICAL CIRCUIT.
3s, ARCHI'1'fiCr sal ION r
C�{. ? 1 understand my Plane shall be used
as pu cords -
or
6 p Licensed I'mfmsinnal re
%ea OWNER-BUILDER DECLARATION ,
W—w 1 hachy of fin loo 1 am,x1,11,1 front be Comemtur's Li,cow Law for the
? following reason.(Section 7031.5.Business and Professions Code:Any city orcerany
$d O xhicb requite,a perms,Ia.room,,,idler,improve.dentoli,n,or repair any n omm re
i3= ,mor u,its issuance,at leynirtstheappresen htr.amh pension file:,signed statement
hat he is licensed formation to the provisions of the Contraccurev License Law(Cramer 9 Sq. Ft. Floor Area Valuation
(,stromatin,with Section]WO)of Division 3 of the It me,,and Ponessioa Code)
or Nal he is exempl therefrom and Inc basis for the alleged exemption,Any violation
of section 711315 by any applicant I'or a permit.subjects Ne applicant to a civil penalty
ofcolnnramntfoc tnndreddollars(as(m). APN Number Oecupan
❑I,as owner of We property.maty mnployees with wages ns theirxule rompco,olion,
will do IM work,and the slecone is not intended or",feria for sale(Sec.70w4,
Business and Pmfesinms ends:The Contractor.License Law dttm not apply to an - 3692103e'�.fired Inspections -
owr,,of property Who build,nr improves thereon,and es who dosuch work himself
rr through his own emphi,ce,provided that such improvements are mol mended or
nutted for sale.It:howevver,the building or improvement is sold within one year of
umpmtion,the ownenbuilder will have tem
e naat of proving Nal Ire did ten htdld ur -301 — ROUGH. PLUMBING
improve Ibr purpose of alaJ.
❑1,n,owner of he poverty.am esch„ively momruting won rne,nad rjuna,les 303 — ROUGH MECHANICAL=r
Lnstruct the pmjcct(see.,Iwo,Business and Professions Coda:)The Cos ntra 304 — ROUGH ELECTRICAL
icense Law does na apply ,,an owner of property who bunco or itnprnves Ihctern.
and who momous fm such projecu with a aoatmmmes)licensed vm.,m.....me 505' — FINAL ELECTRICAL
Co,nmcmr'a License Law. r
❑I am exempt under Ser. _ ,H m P C un this reason -507 — FINAL PLUMBING
owner Este �0 ��NAL MECHANICAL
WORKER'S COMPENSATION DECLAIIAI ION
I hu cby affirm r dcr penalty of perjury one of the billowing Jeclamtiom:
El I have ;rod will rerecho it Cenilicate of Comem to wir.inmm for Workers. APR 12 O 2002
Corpcnsmion, as poordal for by section 3700 oI Inc Lrbm Crwe, for the
performance of the work for which this permit is issued.
❑I have and will maintain Worker's Compensolion livomance,m required by Scclinit BUILDING of the IaMtr Calc,for the performance of the work for ishich this permit is
,.meds My Worker's Congzmatmn Insurance currier and policy number are
nlar:_�(Ae",O�JH l Rr lity Na: LVe197Sr72%
G17RI'IFICATION OF FXEMPfION FROM WORKEiR3'
COMPENSATION INSURANCE
(Thin section mored not be emttple¢d if the i,rte omm hundred dollars .
o lm))or leap.)
1 certify that in the performance of he work I'or which this Fernot is issued I
'shad not eutploy any petwn in any manner so as to become subject to the WbrkeK
Con psrmmion Laws ntCalifnmiu.Date
Applicant
NOTICE TO AI'PI.ICAN'T:❑:ulhs-making this Cenificwe of Exemption,you should
Q pbecome subject the worker's Compensation provisions or the Lahor ,Code,you roil
m li,nhwilh amtPly with such provisiods or this permit shall he Jemmed mvnkesl.
z_
E-, ^ CONSem is rc0NLENDING AGI?get
hereby which'Jr.'Mete iss enm,BaSee lending agemty li,nhe performance
or hit work fm which This roil is isnucJ(Sec 1097,Civ.CJ
a z Londes Name
� Z Lard,,, -
1 cenil'y that I have read This application and state That the above information is
c
[r rnnl.l agree to comply with all city and courtly ordinance,vita gate laws relating
C V
to building mnsmtmim,and herehy authorise reptescnmoves oftnis city in encer upon ”
Sys [r7 me a vive-mentfonal property for inspection purposes.
(We)agree ms;rvt.indemnify and keep bar less the Chyet Cupertino ugainm ,
h liabilities,judgments,costs and expense,which Inay in any way Beane against said
U Z City in ransequenea of the os min,calili,permit.
APPLICAM1 'UNDERSTANDS ANILLOMPLY WITH ALL N,Op�POI
souecE �;m.AnoN~G / 5� IssuedbY Date —•V
signs In"Bramticontmmar D;,w - Re-roofs
HALMtDOUS MATERIALS DISCLOSURE
Will'he appnchm m fawn hailding rwama,v stem m nattmt na awns,Inatedal Type of Ro
to de urvi by the Cover ino Municipal Code,chapter 9.12,and the Health and safety -
Code.SmOon 25532(;0!
13 Yes
o”" All roofs shall be inspected prior to any roofing material being installed.
Wm the 1111)]call or fulme but ting mcnpaml ase equipment nr devise,which If a roof is installed without first obtainin an ins ection, 1 a ree to remove
m
emit hanlrm air comaminatn,as delined by the Bay Area A it Qual sty Managers,on g P g
Di-,Rte'"
0Y" No PP
all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
I have read the haiumnm mmcrial,requirement,under Chapter 6.95 of the
Canh,mia 14ee11h k Safety Code,Sections 35505.25533 end 25534.1 mWonwml That `
it the building Joss not currently home a tenant,that it k soy respomilin itym ramify the
occuptmt nI Ibc requinenenls which nnnl net prior m is,uonca of a Cenificmm of "
Occupancy -
�/ Signature of Applicant Date
owner aroundaxon' /Dart All roof coverings to be Class "B" or better _
OFFICE