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•CITY OF CUPERTINO -A.
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CONTRACTOR:INFORMATION.
¢ WILDING otvtston . PERMIT . -
BUILDING ADDRESS.' - ^ 4 ..
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PERMIT NC
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OWNER'S NAME:' - -
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APPI ICATION SUB DATE' -
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SANITARY No. I CONTROL NO. .
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ARCHITECT/ENGINEER
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BUILDING PERMIT' INTO `'•
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e1.ICENSEDCONTRAC'rok S DECI ARATION - ^' °
•j;h - - Job Description
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I rvovjhy'0 da tl licensed d P f Cloitner 9 (counnuein,
with Selina 7000) ofD'.- Sof WcB I Proll,loon, Cad,nad n1license
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Date Contractor
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ARCHITECT'S DECLARATION
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1 understand mY pin ,call lib used vs pnhlic records
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- OWNER -BUILDER DECLARKI 10
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J hereby off that [;no exempts tam Canhmmr. IJeen. w C the
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following reason. 05ediom903 L5, Bwiness and PmfensmioCade: Any city or connry �
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which requires u permit n, rnn,mmm, ober, improv., demolish, orrepair any s0uemrc
pnrt ni.: uv I. q' th PPI ntf "hp twat 'g 10t eti-
Ft Floor Area ;'
Valuation
@'b r he islicensed Iu the pumikinvoofth Contractor, License I (Chapter9'Sq.
fin n. crag wall section 90001 of Div an? of the Bos n ad Prod s ahr. Cale)
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or dant led is exempt therefrom cordite basis far the an.ged roeptian. Any violation.
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of section 70315 by ary, applicantfor a proun subjects the applarceit acivil penalty
man f,e homebred dollars
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APN Number
Occupancy Type.;
of tsswl.
more
arforyecswthwarsah'sulaee .
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a,i- ' Required. Inspections
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Bthework. and the viumI, iintended B d f l(S7044,
Business d Professions C JeThe'Courracon License'Law does nan
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s arl apply
owner ofp I ry.Wh [miles 'nr d ad who due, sort,-workhimself
arab through h: employees. provided ll t h' p t t
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ordf.It,If h ❑' building ' I t' sold tl year'),
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pl t' b IJ will have the M1trlinef,tim,amr gal' h J'J ntnb'Id
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Intrusive f purpose ofsea)
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Cl 1, s r fihcP pit) ly alternating arml i n0atct
o a t 'theproject (Sea,'1044 B I P C d) theC
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ry
LI I J t iplyt tproperty 'h Funds p th
n contracts t h projects Wlh t acYn{v) licensed p mm t tM1
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C t t L Late.
❑1 corn t IerS � dtPCt this so
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owns 6
W F.R'S CO F.NSATION ECLAR IION'
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IMmby uitlrm under foudtyof perjury.... ofthe fallnwing Jeclarvtions:
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I h o d a 111 rivantion a Certifives, of Consent to self-inser,for Worker's
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Compensation, as providcd, for by Section 3700 Wthe Labor Code, for the
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perl' r a t ¢c of the work fer wh ch this perm is issued.,
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❑ 1 have and will inanition Worker's Cnmpenaatinu Insurance, as requited by Scetion-
3700 of din _Lubl CMe, for the peculiar d o the walk for which this permit is
issued My Worker a Conpensat o a Insurance reel Percy number arc
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C ter: l"y No:
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. CERTIFICATION OF EXEMPTION FROM WORKERS' -
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COMPENSAIION.INSURANCE-
ht sc,
oh_sswlmteed »I neuro,lta dill palms is farads rod dtllata
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(M00)orless.) _•
1 avidly, that in the performaow, of the work lot which this per is issued. 1
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shall not employ anv person in any marder a() as to becons, subject to the Workrr.
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Cmp n at t s ( ),I
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NOTICE AP LICANT g th f t f h pt Y h IJ
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be mM1jccitothe n tem, vt mnrdae Labor Code yo mat
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forth th..amly with orl, moria n. or to pi, cal shall be deemed rcooked. ,
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t�• CONSTRUCTION 1 rNDINC AGENCY I
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the by hich this thea '. a r I'I dngay yf the perfom
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which
octad- k f h h thisp rm l','naJ (Sc 3099 CIJ. C)�
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Lend r. Name
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,benders AJdress
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1 icy tdeal Ith: ppf Y is
'l.tenm
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it s 1 g t o ply with all ty d ty 1 d ante srel'fay
are,
to building construction, andad by th p t i - fth clyl a to P a`
the h mets n"d propertyc p t P P ✓'
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(We) 6 t J . 'fY ndkeepht tictheCo, fCoauthors ,rno
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liabilities, judgments, t' and expe meshmay inany way cannot, against said
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City in consequence of doc granting of this prin t
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: M Date .
SOURCE REGULATIONS'
Signamreol ApprcatNcamre,ler - Date,
-Re-ioofS - -
HAZARDOUS MATERIALS DISCLOSURE,
' Will the applicnm or future frolding occupant Atom or handle hazardous material
-
'Type of Roof ' a •. t .
v, definedby the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety
n - _ -
So
Code, ct ou 255320
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.All roofs shall be inspected -prior to any roofing material being installed'
Will tire applicant ft"b..m'n�neeuaamtsca vt rd,:ccs l -I
pp s I q p
If a,roof is installed without first'obtaming°an inspection,:l agree torremovet11
Nnnsurcot awns a: dafned by the illy Arco Air Quality Manag nim
Isgleto
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'all new materials for inspection. Applicant understands and will comply with `
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'., all non.poin .source regulations.. - '. ..
h N I I' L d Chirpier 6.95
I have mill thehazardoushe
California Health &Sat ty Code,Sections 25505 2553325fl4 uode : that
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fifthehllyd t etlyh have tth.t 1. illyresponsibilitytotf}thc
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occupant ofthe r.quucncos whcmust he met 'nor toi5susue f v Cerreleof
°`°p°"•`r't
Si 'Date '
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f coverings to bClass "B" or better , u - '-
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0%net oraumorvedagent
I.OFFICE r . ..
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
\ BUILDING PERMIT INVOICE OPERATOR: chrietya
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ENERGY
Sec: Twp: Rng:
Sub: Blk: Lot:
INVOICE DATE......:
06/30/2000
REFERENCE TO W
...: 00060189
SITE ADDRESS
...: 21450 COLUMBUS
AV
SUBDIVISION .......
CITY .:.. .'........:
CUPERTINO
IMPACT AREA .......
OWNER .............:
NATARAJAN
ADDRESS ..:.......:
21450 COLUMBUS
AV
CITY/STATE/ZIP.
..: CUPERTINO, CA
95014
CONTRACTOR........:
LIC N
COMPANY
ADDRESS ..
....
.
CITY/STATE/ZIP
....
TELEPHONE ( .......
FEE DESCRIPTION CHK TOTAL FEE - PAID -TO -DATE
BALANCE DUE
13PERMFEE
P
125.72 0.00
'125.72
EPERMITFEE
P
35.52 0.00'.35.
52
MPERMITFEE
P
35.52 0.00
35.52
PPERMITFEE
P
35.52 0.00
35.52
232.28 9.00
232.28
VO E ID
DESCRIPTION
VOICE Ip
DESCRIPTI
304 ROUGH
ELECTRICAL
501 7
FINAL ELECTRICAL
505 FINAL
ELECTRICAL'
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ENERGY