01010036 -CITY OF CUPERTINO ' . y.,., :j
BUILDING DIVISION PERMIT CONTRACTOR'INFORMATtION I,
" DING ADDRF' - PER NO.'
BUIL0 22 CARMEN RD C 0101003E,
OWNER'S NAME I'WOK, 'RATR ICK ' APPLICATION SU131 Art." e'
f�I/.09/o
PHONE: 4 SANITARY NO. CONTROL.NO.
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m0 ARCHITECT/FNGINEER BUILDING PERMIT INFO
u— _ R1, .LE PLUM MFC;
Si
LICENSED CONTRACTORS DECLARATION
z5y� Ihereby B nail Hernial d I rcnpt dr hire tis _ k Job Description
m wens r n m rD' nlnrmeBu and r . cd I 'o p, ADDT1.N 183, SQ. FT. PH# 945 5323
r n - d Ben.
gz� L. vc CEasa L tr
1 11 . 1W3ay Dm SContract... - ?
ARCIiI,BCI S DFCI AIiACION
Luctan,ed Pof..inner
Zi
OWNER Ii Ulf Ufr DFCI C nuraaN
13 a, nr rr tl 70 per m L I , I for Ino 7
FZ_Q roll 6 IS 1 ]01150 : df r,� C 1 AY r n!
S0( p wh h 9 rr. ' P tl .t I It P 1 rh I Y'I'annen V •' \
i3� pr y therrl I1 hpe tl fl g I't lcmcm
that he d pursuantl the provisions r[lie Conioracturs License 1- (Chapter9 s )Ft Flo rpArea - Valu 679
du rg-fh 9c l 70001 f D ' 1 f ih H ' I P f .. Cad)
o 9' •e, ' e �rlhthe e p f I
du the h f the alleged pl .Any vnhl 1 °1
on it T /'
oftioution 7031.5 hyary a,,Ii.nIr = pe-rint subjects theapplicant Ocivil fancily '
or not note than five headed dollars(S500). - , APN Number Occu
anc e
35709011. 00 p Y.�p
DI t, r fthe pr pe,Y.acny empl ) es Min wages.:tn' ole etnp,rivion
d . '
Will the Work,and the structuret intended Or offiared for side.(S 71W4, - - - -
Bu .. I Poressica,,code The C t t License' Law does initapply[ n - Required Inspections",[ '
r,rprepenv wn n'I L' p we m - do d flue
kl lt 101 FOUNDATIUN •,i
wne
through h. pl ! e.I ' dIM1t c V 1: I t 1d'or
of dl Irn the n dl.. I t i,isrold within oney of 102 -- .PIERS '
courp[etion, I bld llhave Ilie both of pmvlgBl he did nor halide,
)np r9rr po. r.n 1 - ` 103 — UFER .
t bl as owner orheproperty,ud .' y courracing sithlicensed cortruchurst 404 — REBAR
odim ire thepm] r(S 7044 prism... 1 d f: Code:)1 h C I oder s
er Lwd Ce p ly n n ld n p ,fence., 105 — ANCHOR BOLTS .,.
and 1 1'1 I n p )CCis
wait
d ucallork) iltabed pursuant La the
Contractor Br 106 - SEWER $.a WATER
❑I �empr a Su it dr . phis re.on ' '
X02 — UNDERFLOOR PLUMBING
woR RSCOMPENSX)Nor,CLARAIION 203 — UNDERFLOOR':MECHANICAL
/ In by i d m g l I rni i t _ 204' — IJNDERFI 6OR.'FRAME
❑ i n _ UNDERFLOORt-INSULATION
c tfi rc m Ir fo rs k 20S '
eo p n[nlon ar provided for by Section 370() or It LaM1o, am, for,tire 301 ROUGH PLUMBING
perier nonce of the wok l '1 1 thio p n r'. d '
111 have awwnma Worker',eelnpe .F 1 : quiroe by Section 302 TUB •& 'OR' SHOWER
3700 of the Labor code,fir me permrnrance or the workefor which oda period i, 303 — ROUGH a MECHAN I CAL
sued,My Win,sets Cnmjxrrtmdon Femmnec carrier and Policy rouser are:
clam : olicyNo, ' 304 — ROUGH ELECTRICAL '•
CERTIFICATION OF EXEMPTION FROM WORKERS' 3,045 — FRAME, >
+ COMPENSATION INSURANCE •r''"
S' uhis red not,, ,re ,odoconprelfa
edhepetndrafin;
orme ,odemar, 30E — HOEDOWNS
sl omorless) ddl307 — INSOLATION.,:"�
ratify that in the r f the workr hnil crack,1 308 SHEETROCN. " 11
slwll net e nl I Y any Da, Y . t h h) t 0 n
r Workers
Cep .Lob,.,tfcll Dt 309.— EXTERIOR't'LATH
•NO7CI LTO APPLIC wT lr R argm C it 0(i afF m r should ` 310 INTERIOR- LATH of
becours,Objectt the Worker's k C I I pan,ivon,orfi LabLahoo,Code,y tel "
' forth 11.....ply
z Q win h n v0( , -
na,orm ni,b,nbeeeenmavokee "311 — SCRATCH COAT
V] CONSTRUCTION LFNDINCACFNCY 313 - ROOF- NAIL. .
.� 11 by alYrm that,ther 'aconstruction' digtgc yf theprfomw
ivn -
nfm kf which this pIntnc,nel(See.3097,Cis.C) 501- — FINAL EL TRICAL',ENERGY
'asz ie.v nail 5 — .FINAL` R,L RING ENERGY . .. '
V O I erryltrlln rand his ppr t tae fr ran the b kr /503 FINAL M HANICAL ENERGY
Ow E,, ear tl g t m u city and Ir d d rr : Iflg J/ 504 FINAL H I'LDING ENERGY"
ff) tnn 'lingc n't i In by d representatives rd .city to t upon. - _
p m then 0(p p ,yf p r Ina 50 — FP,NAL . ECTRICAL
� Qt (WO g I d nl r ilk l nn "IheCty fC p tnoag , - .
m liana, . ) eg the ......which ,v hath, v -'sena a 521 GAS T S
C n and,- ,her or thegOarraigof his recruit, ` .w
F 'OUBC REG N ATIONISNDS ECOMPLY WITf ALLfNON'POINT Issued by: Z SID F N L MB I NCbate' �/.
.igra rcn Appan,ran Cocurre + Data Re-roofsOHIO. t• - .
HAZARDOUS MATERIALS DISCLOSURE S 9 — FINAL GRADE -
-
Will the ppr t future 1 leid 1 lima recon ml L..n n ter;al Type,of Roof - ' ,
n, t d by the Cp tiro Mnee pal Code Chapter 9,12,and the l with and Safety 5 0 '°- FINAL_ PLANNING
Coe Section 45532(0() . - '`
. ❑You ON. :All roofs sh(all,bei teitp�`tArW%ny�IJKg�atJt�l�rlginstalled.
Will'he applicant or future all liing occupant a,c equg,nicnr et dev ice,which If a roof is installe without first,obtaining aminspection,.I agree to remove
emit hvmrdoue vlI Cemnmindub,oda defined by the Bay Arca Air Quality M;magemem -
DWoriceorea ❑No - all new materials for inspection. -Applicant understands and will comply,with `
all non-point source,regulations.
I h d he lialando.,ito to,,Ldnernerb,un Ic Chapter 695 of the
Cuffan,.'Hcaph '' yCnv Sections 25511.5 5591 and 25514.1 ily'Wndthol +• 1e -
IIIhe building t firmly1 a tenant,unit iris iY res,abObAny I, trythe
_ occpantofgirre9ur n.wlichmsrb mm pot a of a Ccrrilcam ofCredence
. 'Signature of Applicant '-Date
Onto Or authorized agent • Date . . ,AIL roof coverings to be Class "B" or better
6. r
OFFICE