00080178 nniHii RoINO
� IvCONTRACTOR INFORMATION:
PERMIT
,.IIINGADDRESS: „y PP.RMT NO,t
11A I
OWNER'S NA. •. ^ ,•' AI'PLICAI'ION A
E
le ppO •AR - BUILDING PERMIT INFO
U p r r BLDG ELECT PLUMB MECII
y.Q y
S N j LICENSE.D'CON TFACTOR'S DECLARATION � - Job Description
5�_ Iherehyefiirmthar lam licensed unJerpmvisiom of Chap¢r9(commencing _ - ,
_et�i, with
mm' els:zSa I, M_
•.
°a LLL cnntmemr. 7 PATIO ENCLOSURE
-� ARCHITr:Cf'S IIIiCLAR,�Tffl � '
y 1 underslnnd mY Plane shall be uxd lie public recnNx 1 \
a p Licensed Professional - '
o OWNER.BUILDER DECLARATION
1 I...sby off....manm .
+I uuta f a,the Contractor',,License Law for the'
(_ ¢ following reason.(senior,7031 ii,un+incea and Professions Corm:Ahy city or county .
HH. which requires a permit to constmct,alter,improve.demolish,or repair any swcmre
.E. prinrwiec issuance.uiw requires me appliam for such permiuo Hleasignnl emremem
thin he is licensed pmsuunt to the In of the Corr motor's l.Iomm,Luve(Chapter 9 Sq, Ft. Floor ALC' Yalnatlon
(commencing with SeaJn 70(p)of Di...it Sof the Basile,nod Pmrnmm�u Code)
or that he is exempt therefrom and the basis lot the alleged exemption.Any violation
of Section]Ill 1.5 by any applicant file a permit.subjects the applicant m a civil penalty
of not more than rive hundred dollars(s500). . -APN Number Occu
0li as owner of the prolicny,or my employees with wages as their sole complamition,
will till the work,and the structure ie not intended ar oRe,ed tier sale(Sec.]BH. �Fj ,,..//77rf
Huxiness and Professions Cale:The Connector's.Licumc Low does not apply to a9'3405]
Zan u 2 •Lfe�llred inspections
wnor or Pi^Pony Won builds in improves da,run,and who docs such work hirnsoll' + -
nf through his we employees.,provided that such imp emm
ecnr,me at intended to - -
offered for xaln.If,however,the building or impmvementis sold within one year of 101 — FOUNDATION -
`ompletion,the mone,huilder will have rhe burden of proving tom he did m,not build _ '
Inpm,e,ra purpose or suit.). - ”' 102 — PIERS ,
❑Lasmvneronheprnpenr.amexewsi.<lyeelmmclmewi,hliens. dc,,nt.al..t. 103' — UFER .
stmn the project(Sec 7(94.Business and Pruresalons Chile:)The Commti
cr's
License Law does not apply w on owner orpmperty who builds or improves mgmmt, - 104 — REFA R
cO,Ind who contracts for such plns will njea eommcmgs7 licensed parcuanr m he 105 — ANCHOR BOLTS
ntmetnrs Liceme loss.
lam e.mnpr code,So. It at PC for oil,renewer ] ITFr — SEWER R•' WRTF_R
Owner Date -
WORKER'S COMPENSAPION DECLARATION 20'?_ — UNDERFLOOR PLUMBING
I hereby ares..rrpder,pm,alty or penalyymeof not fopawmg delivintinm,: 203 .— UNDERFLOOR IyIECHANTCAI.:,
1 have and.,if prorraidraln a Cenificlle of Consent to WIN...re for Worker, 204 — UNDERFLOOR 'FRAME ..
Cnml,ensmion, as vided for by Section 377) f',he Labor Cole, for ,he
perfon,tantemnheworkrerwm<hla,,moutisissued 205 "— UNDERFLOOR INSULATION
❑1 have l a l will maitimirs Wmkcr' Compensation in,aroec,,egaired by Seddmt 301 — ROUGH PLUMBING
3]W of the Labor Code,for the performance of the work for which this permit is -
i steed M Wtrk ' Competitor I "move earril,andrane 302 — TLIB R• ,OR SHOWER • .
�yy number ole:
artier:✓`^s /a Policy N., � f 303 ROUGH MECHANICAL'
CERTIFICATION OI'EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE { 304 — ROUGH ELECTRICAL_
(Thisseoimareada.,hecompleted ifinepamtitf fof,mehundred dollars 305 — FRAME
ISIBB)artms.) 306 — HOI_DOWNS .
1 eerily mit in be III plaster m work d,which m','lienar is itsnen,I 30'7 — 'INSULATION
.hall nut employ any person in any manner soas m hatione subject to the Worker' `
Cion,mmlon Law,put California.late
Applicant 308 — SHEETROCNs
NO]ICEIO APPLICANT:If.afro,ninking his Clailliantit"I florannumt,'Or should -309, — EXTERIOR LATH
O � hecmne subject m me Workers Compe,natran provisions lithe Ether Cada,you must '
' rano imenmplrwsn,mcnprmicignearmi,p mir,nanxdeemedrevakea.. 31.0 . — INTERIOR LATH
CONSTRUCTION U NDING AGENCY
C > Ihereby arson mat mere isacon.m,nion lenling agency nor rhe performance - ',.+11 — SCRATCH -COAT. .
,if he rnr which this permit is Issued(Se,San,Civ.C.) 3].3 — ROOF NA I I_
0. Q Lender's Name
u o I,endereAdimx^ 501 — FINAL ELECTRICAL ;ENERGY
V. Icedifythat lbvemad this application andstate mnmeaba.einformation is 502 — FINAL PLUMBING ENERGY
Prect,1 agree to comply with all city and count,,ori inunces and state laws reining
O'V ro'building construcmin,:ndhereby authnn.ereprmrintivesofrhis sitYmcntrition 503 — FIN MECHAN CAL ENERGY
.
rhe abovo.menttoned property for inspection purposes.
y 4,1 ,8
am.cave,,ndernmryan eepn ,nmsstheCityofCupertinoil,i o 504 - AL BI-IIl_D dG ENERGY
V) liahu,co and ape onto may in any way acerae ugaZ"
.a sail
v /a etyD',c gattril,e emit. 505 FIN LEC ICRL
DE ANDSA ILLC 1PLV Wrrb ALL NON. )I
ar Issued by; 506'- - •f Date �a
Signmure of App lenUCnmrunor %i RC-r lofs '
HAZARDOUS MAT UALS DISC obridl ''508s INAI- MECHANICAL_
Will the c Car�e w frure building occupant store 2,handle h boas material ' Type of Roof
as Code,
Sedio rheCupeninu Municipal code,Chapter 9.12.and rheH alioand Safety _ 509 . FINAL GRADE
Code,Sectimr 25532(n)'1 '� '
13 yes ..ON. ' All roofs shall b5ftf9fieetecFpTk Amb aWrAflilij NiQerial being installed. . '
Will the applicator orfuture building mediator use equipoantordeviaswhich If a roof isinsta[�gl4vithogFtjtlS►Fplb[a�AlhgiLilgjT]sppyQRp;�agreeroremove
-mit ha audoov air conmminoms ac defined by me Bary Area Air Quality Management
built, all new materials for,ins ec,tion. Applicant understands and will comply with
❑Yes ON. P,'. PP PY
_ •'
all non-point source regulations.
1 have read thu hu and as parranals requirements und•r Chapter 6.95 of the -
Cullforn,Uvalrh& IetyC d Section'05505 25543 d 5534 I c dram
if in bor uI ice of cu n lime am thatlsny respn iht�onntifgtoo-
cecupam al me yuirem thick h
lit"
es v to issuantt of e YYili/iii Ill
'
cupanc -
Signature of Applicant Date
Owner mnadaen agent IDate All roof coverings to be Class sB'•or better ,
.OFFICE,. „ -