00110120 CITY OF CUPERTINO
BUILDING DIVISIONPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: - PERMIT NO.
22015 CREEKSIDE CT 00110120
OWNER'S NAME: APPLICATION SUB DATE
HARRISON' 1,1:/22/cab00 .
PHONE, SANITARY NO. CONROLNO.
O C 2Q ARCI11'fECI'OiNGINISI3R: - BUILDING PERMIT•INF0
r HIDG .. ELECI' - PLUMB MECH
< I.1 1=1 1=1 IJ
LIC17NSED CONTRACrOR'S DECLARATION
ym
.oZ_'' ation70:dBrlalet Iamoftheaumlerprbddnns.n�Chmncaondannenemg Job Description
r'_I—u� with full force anquf DlvixiunJofthe BueinessnnJ Pral'easinn.Cute,and my liceme -
ay ts
Date reean at' qi REMODEL ONE BATH ADD I BATH
g�gz Licenec Cl..
� (c[y��/ f - ,
u7 3 m Dave S DEC mRATION •_ L�^•rt'1— - • .
ARC111'1'ECr'S DECLARATION
IundeamnJ my plans shall be aeAmpublic recunls
y6 o O Licensed Pmfecsinnal '
OWNER BUILDER DECLARATION ,
I he by affina h t I ant excialut train th Conciliator's License Law for the
fall ,wa: �(Seei ]UiISN .ina 'andPrl eld :Ay 'ty irtenun,
$x 0
which nature,a glaredn construct..lair,narrate,J lith;or mInti,any stn emre / _
priort , issuance,al. 1 theapplicant f r u.h water titfile a signed storement
bathe is liAntwul,uaun in tomeprnwahootlacC nectars Licenne Law WhaInov 9 Sq. Ft. Floor Area Valua7:0:0:0:
ion 4� <
econtmeacing with Section]11101 A Division 3 of the Bushes una Prnl'essibns ode) ' ' • $7000
tio .
or mm he is exanpt therefrom and the basis for iM1e allege)exemption.Any ns Co e)
of Scouter 71131 5 by any applicant for a pemhit xublems me applicant u,a civil penalty
nfnen moremanrsehulldreddol lurs f$5Qd. APNNumber - Occupancy Type
❑1.naowner nttheprogeny ornhyemployees w;th;,ngean.marmlecnmpen.aenn. ='F,39038, 00 .
will Jo the work,and the strunu.e is nnI imeaded or offered for sale(Sea 7(N4,
Bnsho„aad rrnra nh 1,Code:'I he cnmmemr•x.Licauxe Law does nm apply;,,an. Required l nspections
in.nei-of trropeny Who builds nr improves thereon,and who does such work himself
or though his own employees,provided that such inhpmsemmnts are not intended or 101 ' — FOUNDATION -
offered forsale.II;however the huddling or Impovcnhcat is said within one year of '
comple tat,me owncnbmtder will ha"e the burden mprodihg that gndia not build it 1.02 — PIERS .
impm.eorpurponcnr.de.), 1.03 — UFER
❑I.ax owner tuf Ice mnpeay,wn u.cla.ively conlmminc nim ItrenreJ enmmemn us. -
ureachmeoesne(sec. tou.Baaletronna'rrywhobxa,m:)Tnecontcobrs 104 — REBAP.construct the
Law docsnalapply toojownerofa r,aan who halms impmasthereon, - -
C. woo enmnhcuse Lowucn rrnieetx winl a nmcetolrm licensed lu,unm m be 7.05 — ANCHOR BOLTS
Cbl a.cirli trade Law. , -
❑IamcxemptunderSee. ,13&PCto,his nation 10E — SEWER &' WATER
Owner - Date. • . 202 — UNDERFLOOR. PLUMB.ING
WORKER'S r.OMPBNsnnoN DecLnlinnD" 203 — UNDERFLOOR MECHANICAL
rrn
• Ihereby anunder penalty oiperjuryone othe following declarations 204 _ UNDERFLOOR- FRAME ,
❑ 1 nave.,to uIll maintain a CeniEeme of Consent to self-inure for Worker's 205 UNDERFLOOR INSULATION ,
Co."nnmion, as,provided for by Section 3700 of the labor Code, for the
perrnr,na..nrme wck tai which this pc,art is k,o,d' - ' .301 - ROUGH PLUMBING
❑Ihate andabor Cine, Worker's Cuac..re f]he workbn,required by Section 302 — TUB R OR SHOWER
3]IMI of the Labor Ctdo,for the perfommncu of,he work for which this permit is
o,U,r1Mywgrkerscnnlpun.arnahxurancecanie,�ncalI'l'llreymm�crara 303 — .ROUGH MECHRNICRL
cmen�l policyNn:�Z/�b�^� 301 — ROUGH ELECTRICAL
CER MFICATION OF EE%EM"ION FROM WORKERS' y '
COMITT NS A][ON INSURANCE 305, FRAME-
(This walion need Nat b;counnemd it the permit is fortune hundred Jolla, 30F - HOLDOWNS -
(SIINryrnless.)
307 — INSULATION
I certify that the perfnrmance of the work for which this ct ,, a ironed,l
shall not employ any!Cabo in any manner s,a,m beubine nan;em m me wckers' 308 — SHEETROCK -
Cmnpcasarm,l.awsmc,I°hunlaDwe 309 EXTERIOR LATH
NOTICE d
NOTICE subject
ctAPPLICANTWork is Compensation
this Cerebrate M Escalation,ion,you should
necnme.filo;emcm<wcwer,compunxahnnp,n.ixnhnsnnlhewborc«m,you lauxt 310 ' — INTERIOR LATH
'z forthwith complyw'Ill Inch pmulxinn,nrIll iIpermhahall beticemedravokod, 311 — SCRATCH COAT
r
h
CONSTRUCTION[.ENDING AGENCY' ,
a5 Hereby which mut mem is a esued Scea acorns aenauy for me pe bnmmca 313 — ROOF NR I I_
i C Lan'he worl HE,rwhich
Bhis m,RLlsxaadrsea.3nm.eieC') 501 . — FINAL ELECTRICAL_ ENERGY '
Lander',Name r
z
Leral Address 502 — FINAL PLUMBING ,ENERGY .
U OI unify that 1 cloudy
mite this city
ad co and state rent aha above i:laws re ai is 503 — FINAL MECHAN I�CRL ENERGY
kr F. tortem.1 acme to comply with all taut and enemy ordinances and nam taws miming
f,J mabobuilding t d n do by uta u p t t •s fm:city to ¢r upon
w meanpI p tyfrm:pel p 504 . - FINAL BUILDING ENERGY
[..I L (W) g t Lae J fy dkclh .theCity fCapron.agama .
vy Ind, y dg u1 ' r which y y -yarn ghmt. id 505' — FINAL_ ELECTRICAL
IA�Pl(,are o nprlivamicon Ie h�I •o, 504 — GAS TES•G -
e abr.nl hg nC this n
MI'1.YWITH ALL NON PO NT IsSUCdb
� Y Date'
HAZARDOUS MATERIALS DISCLOSURE
u'e Re-roofs 908- - FINAL MECHANICAL_ `
Will aleuplhcaut car future nalaingnccupam nom or handle nn,mdou,mam,;al Type of Roof 509— FINAL GRADE
as delinod by me CarerrlmhM eipgl Aida,Chapter 9.Iz.trod Ile neldm amt SlJaty, _.
Crile,Section 25532(:0'� - 51.0 r, FINAL PLANNING-
0Y" No All roofs shall.�ligfs ectec�I$fl 'Ito Wlf toqu TfL'�t 1,b g
p— i o r cin installed.
wll Ossudir Ecmu m1 uwbnaiMiag"eeupam yAeaAirQu otdMare"whion If a roof isyinstalled without lrst obtaining an inspection, I agree to remove
emit hummnus air commninalXs n.def neA by me Bary Area Air QoalityMwagelnem 6 P g
.
District? \L all new materials for inspection. Applicant understands and will comply with
❑Yes No P pP P Y
all non-point"source regulations.
1 have read the heoral materials requirenrclns under Chapter 6.95 of the
Cut rnmia Health Csde.Sectium25505.25533 anJ25534,I'understaral '
if the hullhl molly huvoatenl,m;shot it is my resrymaihility m'nmily the r '
menof ren. s I he Ire,prior m issuance of u Cenircmc uf' '
t90 'Signature of Applicant Date
owners amhcrred agent Pa, All roof coverings to be Class "B"or better
OFFICE"