01080120 CITY OF CUPERTINO
BUILDING DIVISION PERMIT i CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
1169 CRESTLINE DR 01080120
L��"M C APPLICATION08/24/2001
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
w BLDG ELECT PLUMB MECH
H« u o I= u
LICENSED CONTRACTOR'S DECLARATION
5'�= Job Description
i z-co I hereby affirm that I am licensed under provisions of nsClOspru Code.and
mmmm�se p
ua�ro with Section 100070 Division].(the BusincssvM Professions Code.end my license ADD 570 SQ. FT.
x E
X d�.! Q in full forte an ,. O c Lic.p ARCHTECI"5DECmA7 N r-
f FIp
LED
I understand my plans shall bused as public boards
xn o Licensed Protection.) JUN 14 2002
OWNER-BUILDER DECLARATION.
u� o, 1 hereby affirm that 1 am esempt from the Comm ute's License Law for the
!' following aason.(Section 7031.5,Business and Professions Code:Any city orc.unry $57000
o which no ims a pconn to construct,alter,improve,demolish,or mWir any structure
�m
(commencing ingnme,also requires the applicant for such permiuofile a signed summon-
Shp,hmenclb a'mdpSecttihitdlhe of Diision She Conoacwls License (Chapter 9 ode) I'T-3�2� O�r'�a� • Valuation
waNtecdon JOfmofhe basisaof,e.111,dcloud ProfAnyvsCde) {..)'SSL....:. , L�1,l.,4l,li_t5• I
or,hai be is exempt theicfrom and the basis for the allkkged d,emp,iod.Any violation.
-o(Stttion903If5 by eny npplirnnrfa v prnnit subjms,hc applicam m o civil penalty
or not more than five hundred dollars($500). 10 lAP-N h OWNDAT ION I"' Occupancy Type
' ner.f,he property,mmy employees with wag=s asthcir sole compensation. 102 - PIERS I
will do the wmk,'and the r,runure-is no,intended".,-offered"for'sale(Sec 7044,
gusineis and Professions Codc:The Cowmcur's License Law does not apply in an 103 - UFER Required Inspections''''"�"
.on,ofpm,dy Who holds.r imp..c,,hem..,nad who does such work himself 104 - REBAR t
or through his ply provided ma such improvements are on,intended r
:.-ofleredf 1 If,however,the bullger i is soldwithin now,yew or1'05 --- -ANCHOR"-BOliTSI v
completion,,hcomer-builder will have,he harshen of proving,he,he did not build or
improve rsme). '
•_.'
. ._ ... _._.
106 - SEWER & WATER ,
-------
<� property
O.I,rwas<otwne—r of he pr. n y woe.<-'u"-ski. 1''.voce- "gwm" fian
e
_ nmouto ..... .- ' UNDERFLOOR_.PLUMBING-
he pr.j=er(s= vo ,eurnerrndProb:ti.nsCoa=:)The
C.,a<mrs 203 - UNDERFLOOR MECHANICA.L...`,_p-.,_, ..__,_.... ._n...t'" ''';' License Law dasapply toan.waroywhobuildsor impovernkrt.n.
and who cs.fsuch pr.ttu.with.v.<onwctogs).licensed parsuammtne
Commit Li`eneLc _ _204UNDERFLOOR-FRAME
eaPc .r,nismu.n 205 UNDERFLOORi�INSUliATION01amenempde, ..:_.a.'...-..-.-..-.'
--'-or--
l:
OwnerDuan' ^' ' 301 - ROUGH PLUMBING _
WORKER'S COMPENSATION DECLARATION 302 - TUB & OR SHOWER
In=mby affirm.der penalty gr p<rj�ry bo=or me r.lmwmg aeaara,i.nr: 303 - ROUGH MECHANICAL
❑ I have and will maintain ar nifi=am of Conserv to If inside for W.,k=ra 304 - ROUGH ELECTRICAL
Comp,mrso m-as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.,, 305 - FRAME
❑I have and will mainiain Worker's Compensation Insurance,as required by Section 306 - HOEDOWNS
3700 Or fie labor Code,for,he peRomunce of the wank for which thispermit is 307 - INSULATION
i1 a , My W h tis Compenut on l er enJ Pol cY Mart ---
: rol=rNo ---
f' ti309-! t XTBRI(jR aT,n : ``'' 1 14::.
CERTIFICATION OE,E%EMP ION FROM WORKERS "
COMPENSATION INSURANCE .."`•' I' -_
,--.—INTERIOR—LATH.^.�_----._._.- --- ----- -- -----------
'flltissm" Oncd no,be completed Hine Permit is for one hundred dollars 311r5' SCRATCH COAT
' (t100).r less.) "
3-13 -•-ROOF- NAIL ----.
--- ' I ceruly Shu in th pert,mance of,he o k'(or Mch th pemd,u'issud,
11 , mployany Pe awry man sto beeom bec,t ,he ,kers 501 - FINAL EliECTRICAEF-ENERGY
.m o
ct sore C9 �f
Applicant gff't k f° '"y. 9 :.. �—c-d . ._ _502 - FINAL -PLUMBING. ENERGY. _.._
'NOTICE TO PUA� CAM:I�.1 mnkin this cenir=nm of Ex=mfi.n,you should 503 - FINAL MECHANICAL ENERGY
become subject to Worker's Compensation provisions.fiche latia Cde;you must
Oz0. f.ithwimc ply withsuch'provia..,tohiso<.itrh.Hbeaeemdrcvokm. 504FINAL BUILDING _ENERGY, _
_ .
n CONSTRUCTION LENDING AGENCY
" 505 - FINAL ELECTRICAL I 'H
,0.a.�, 1 hereby for affirm that them is a issued
Seon lending agenry for the performance
�. alio kr w,h<nmsperrnt s ,arc)' 506 - GAS TEST '
a(sec 3091 c -
lyq Ica Name ---507' = FINAL- PLUMBING . . .--' - •----- ..._ .._ __ ._ ._.
Lend Addrc s"
U O. '1. I certify that I have mad this application add state that the above information it 508 - FINAL MECHANICAL
ear=, 1.'reco,comply with all city.and countyordiran< d.,, ) s mains 509 - FINAL GRADE
0.V to Wilding t ctim and by amfirm ep . 't f ea f1his city, mics upon
y W. .the wwvc+mrmimrdpmeryfor inspection purposes. 510 - FINAL PLANNING
0. (We) co eae dinnif and keephmle
asstie, C't of Cu nnoa against
liabilities 3 dg nt. rest,Old expenses nses whh , y in any a °y accrueagainst skid+ 514 - FINAL PUBLJC WORKS
City in consequence of the granting of thispc ,.
'APPLICANT UNDERSTANOS \ L COMPLY WITH ALL NON-POINT'° I
SOURCE REGUI-AT,DNS i n Issued by: Dale
m, f
'logninumfAppl<a Ile t t s' Date Re-roofs
HAZARDOUS ATE ALS DISCLOSURE u
Will the applicant or furore building occuparm store orhandle hvardous aboacrial, Type OfROOf --
asdfWbyNCupcnoMuneplCotleChap,
.cd or zss3z(a) „1 ON' I.. tP ,�tit 1" 1 , .: i '. �= S-. z:11 t A,. .;;.d',
' '? - - _Al]roofs shall be Inspected prior to any.roofing material.being.installed--
Will the applicant rats building ac pa tuse equip
ecqup , dem wb"<h If a roof is installed without first obtaining an inspectiofi;Tagree'to•remove
ern harardous nr comamments es defind by,he Bey Amo Air Quality Menagemrnt
°ismer .. . - .,❑Yes ON. all new materials for inspection. Applicant understands and will comply with
' "- all non-p6in[source regulations. ,1„ , -
•�� s: 1 hese mad Ne'hvard 'maurials mgmmmenu'under Chapter'6.95of the
Cal
a ifomia Health&Safety Code,Sections 25505,25533 and 25534.1 understand thin
ifthebuilding doe snot currtmly hvveamnant.,hatitis my mporisibiliry io notify,he- " -- ' - - -- -- - -
cupis of Nc rtquircno ms what) st be me.prior t.issuance of a Cmifirwa of ' -
Qwupency. ._
(,u-f 7 _0/ Signature of Applicant _ Date
Owrrmwaudmrirca=s an,' Date_ All roof coverings to be Class "B"or b6ti&"
OFFICE .. ...