00060065CITY OF CUPERTINO
CONTRACTOR INFORMATION:
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nUILDING DIVISION - PERMIT
HUILDING ADDRESS:
PERM I'I'NO. '
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OWNER'S .. - a'
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APPI:ICAI'1 S It 1'
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SANITARYWY,
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ARCHITE=,NGINF-EH:
BUILDING PERMIT INFO'
NLDC" Ii1.liCT PLUMB MECII
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(LICENSED CONTRACTOR'S fiECLARATIOY
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I hnvhy aflirm ihw 1 tun IicinsW under prnvixinm of Chapter Y (commencing'
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with Section?000) cf Division 3 of the Business, trod Prnfcasion, Code,nndmy license
ism force
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full and effect.
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Dut I a HUILUFR DI CLARATIcon
, pt tl C t L Law for the
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loll wi rums.. (Section J031 5, Rus fie and Profess t ns Coade: eAnypo city o, county
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which rcquircs a peiron i or rcpar any
cores
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requireshpermitdert
priort t '. I. e9 .the rPLcam for such puma a fl signed t mmem
e the appliither.cant tfor such statement
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Sq. Ft.,Floor Area _
Valuation
th,tl tire . dPursuant t th 1 mortu:Contr,ctor Li el (eh,tpter9
(eommeneing with Section 9000) of D's s me 3 of lbs Bui msv and P'nl assmns Code)
or that he is exempt therefrom and the basis for the alleged exemption. Any violation
of Seation 7031.5 by any applicant for a pennit.snhjees the applicant m u civil penalty
,I not more than five hundred dodum PSNB
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APN Number
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Occul a pe
❑ I, as owner of the pm Fairly, or my employees with wages us their sole anmpensati,in,
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will do the work, and the structure is not intended -or offered for sale (Sec. 7044,
Business and Professions Codc The Contrw or'x License Law does not apply to an
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- _ Req Dlred Inspections
urv1mr of property Who build, in Imp}oven therein, and who docs such work himself
m,h his nova emphryces. provided that .ueh improwmeivs are m,t parinlm of
offered for sale. If, however, the building or improvement is sold within one year of
ON . - '
101 — FOUNDATION
completion, the owner holder will hive the burden of proving that he did nm build or
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improve for purpose of sale.).
102 - PIERS
❑ 1, as'owner of Ne property. am exclusively cnmmdiag with Iicea,,d contractors to
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103 '— UFE R Y, ... .-.
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conamet the project (Sec. 1044, Business and Prific sinus Craft, I'Me Conuaamr's
License Law does not apply to an owner of property who builds top ves the inn.
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104 — RE BA R r .
and who csmtmetr forh prof is with ntractons) licensed p want i the
CnntmOur', License L
1.05 — ANCHOR BOLTS
❑Iameremmunder Sec B &PCIrwhisonsom
]Q16 - SEWER d WATER
ownr. ,WORKER'SCOMPEN`SATIONDECLARATION
' 202' — UNDERFLOOR PLUMBING -
embyalrmtunder prally ofpdo, ,as ofbelbllowingdedamhnn,:
203 —"UNDERFLOOR MECHANICAL'
1 have 'and will Cmnlntain a Certificate of Consent m self -insure for Worker's
204 - UNDERFLOOR FRAME
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',npenxahon a, provided mf by Seetion 9700 of the Lanor Cale, for aid
NeMmumpeeofthe„orkforwhirnthispennitisissued.
205 — UNDERFLOOR INSULATION'
0 hmx:md will maintain Warker's Compenwtion lnxumers as requires by Section
301 — ROUGH PLUMBING
37N) of the Lahpr Cade, for the ,hrman,v of he work fm'whicn this period, is
302 — TUB & O R SHOWE R
wed. My Worker's Compensation mxurance carter and Policy nwnM:r ore:
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ame. Policy No.:
303 — ROUGH MECHANICAL
CERTIFICATION OF Ui EMPTION-FROM WORKERS' -
- 30/} — ROI ELECTRICAL* -
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COMPENSATION INSURANCE
-IGH
Cru, ,ectionneedno WcmnpleedinnePermitisforoorhundreddollar
305 — FRAME
(tloo)Frmss.) - -
306 — HOLDOWNS -
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1 remly that in map , ommncu of toe work h,r which this panait is soted, I
307 — INSULATION
.hall not employ any p nos in a •r so as t herm,t� In sit m mr woke
Capo emanon Law D t f
Applcant -
308 — "SHEET ROCK
NOrCE 10A PT C 1 1t t fEmnapi i,y xo„Id
309 — EXTERIOR LATH
O'0
hec., xuh)om m the W k (. pe all t p '. : f the Labor Cwt y u amt
ronnwhhrnmPlywm uchprovtsomotb,pe rnit hmlbed •mmrevokw. t
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310 `— INTERIOR LATH .. .
FCONSTRUCTION
LENDING AGENCY. '.
311 — SCRATCH COAT
a
- I hrrehy c inn that there ion mnshueion lendingugvor, fur @e Pednnnener
ofthewokfinwinchtmxp .it ixissued (Ser.3091.ay.C.)
313 '— ROOF NAIL
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Lender's Name'
Leade,.,Adl e
501. - 'FINAL ELECTRICAL' ENERGY
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I dent I, thin 1 have read 11, is airldwittion ond sund I bill the above nocannin on is
502 — FINAL PLUMBING ENERGY
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comics, I agree to comply with an day nod county srdinimm, and same Inws reliving
m building construction, beat mpresentutive, om f this city enter uq,n,
503 — FINAL MECHANICAL CAL ENERGY
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w
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tneabn(We) ionedpmpnyfor iayandkaporoses.
Culamin nobsiimm, nd
(Wc7ugreod,scasti
504 — FINAL` BUILDING ENERGY
m
V z
ndelfyann whip maylss, mCity
costs and e.penahi which may in any way aceto agmmt sin
Cliabilities.tyconsequence
City in consequence of the graining of this permit
505 — 'FINAL NAL' ELECT R I CAI_ -
APPLIC UNDERSTANDS AND WILL COMPLY WITH �A1 t, NON- INT
S
Issued by: 506' — GAS TEST Date
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— �—.� _ - �2 Oa
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Signature nl Applieam/Entao ate
R�roofs `11 10— - - -
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AZARDOUSnIATERIAISDISCLOSu E
508 — FINAL MECHANICAL
Will the applicant m future Wilding occupant store or handle haxanbus amnamd
Type of Robl,
Cade, he Ct
509.'- FINAL, GRADE..
SetnymeeupeninoMCtdrq,aleotn.cnttprer9.Iz.mamapalthandSafety,
Code• Section (a)'f a
Dye, ' I C3No -
All roofs shalFUAn.s ecFed tcGin NMtI '
g gii�ic 1{�Cmaterial being installed.
Wi 11 the appQrl;I or fumm M1u inlinb occupant use equipment u; des ices which
trn�'��1
•Ifa roof is insrfidl4d 'Wit VtRI441t?t{Lot1%UE It10 itWW4R, I agree to remove
cont havudoos mr emtmanhad s as defined by the Boy Anil Air Qoolk, Momip nmm
District^
all new materials for inspection. Applicant understands and will comply with.
ElY`s ElNo
all non -point source regulations.
1 hove rutin the haaardaud mawrimly mryiremems wader enuptcr 6.95 of the
t
Health&Sufaty Code, Secfmm 2$505, 25533and 25534'. I understand Octfthe
building doesma cumntly boom o mdant. thaitis myresponsibility to notify theecupant
of she requirements xrich must be met prior ro issuance of a Cc ificae of
4Califionds
crupamr .
ignature of ApplicantDate
All roof coverings to be Class "B” or better' `
wneorauthomzmage Date
OFFICE