01060080 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10101 N DE ANZA BLVD ASSOCIATED CONTRACTORS C RP01060080
OWNER'S NAME: APPLICATION SUB DATE
�• FIDELITY FEDERAL BANK 840 JURY CT 06/13/2001
PHONE: SANITARY NO. CONTROL NO.
4089771400
o Q O ARCHITEC iENGINEER: BUILDING PERMIT INFO
U— BLDG ELECT PLUMB MECH
Haw LJ I'- I I=J C_I
Z t y I hcmby a LICENSEDa CONI R CTOR'S DECLARATION Job Description
O z_ pmvisions of Chapter 9 Uommco6ng
r Hr_w with Scnion]IYJ01 of Division of the Business and Professions Code.and my license TENANT IMPROVEMENT. (2ND FL. )
a y is in full force and effect
tt 6 Liccnx Clayys Luc.a O t t S
O Dam f0 I Cnntmctor Y -'i LP+'Nc /
w 3 LL A IT,CIS ECLARATION
C=O 1 under,la my pP ed as public recoNs
ce
ce
a O Licensed Professional
y OW -BUILDER DECLARATION
1 hereby affirm that 1 am e`empt from the Comracmr's License Law,for the
t'z following reason.(Section]0315,Business and P ofersions Code:Any city or county
swhich requires a permit to construct.alter,improve,demolish.or repair any structure $150000
us primm it, 1nre4 dr ppl icon,f h prosudI MC a signed.t Icret - -. - _. - - _ _ -_-- .. _.. -
thatw, dpi da tt tl)epo curs Ofln Cot el Li h (chapoul) .{S�1 l- �{p. Pryor l Valuation
I(o curb ith Sea )000) fUvi: t fa B :' ca' d1 fe.' ns Lode) f'r y"�v. �:3L03 �V
or that he¢eacmpt therefrom and the basis for the alleged exempt on Any violation "�1
t—or Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars(s500). APN �' .. . Occupancy Type
101 - WbVbATION
❑h m owner of the property,or my employees with wages as their sole compenamlon.
will se the work,and the ade mT e s not intended oreLaw for sale(sec: us as 10 3 - UFER Required Inspections
Business a work,
Priffe,ti...th strut The Comtainten dorLiceoffered Law does not apply 0 un '
owner of Property who builds or improves thereon,and who diet,such work himself /
or through his ploye provided thalh improvements are not intended or - 104
offered fo 1 If.h the building o- 'pro .t is sold withincons,years of -
completion. owner-builder llhave
tm burden provingrthat hsee not build or 105_ .-- ANCHOR BOLTS
improve for purpose f. )
1r
106SEWER &. WATER
"ol c, h fihepropertyexclusivelyandP cis tar licensed sec 202 - UNDERFLOOR PLUMBING --
o W t th p 1 t(Sec,]IlM Business J Professions Codti:)Th C ntra<tor's
LI La doe t apply n fproperty hoWla p thereon, 203 - UNDERFLOOR MECHANICAL _ t
and-who c t t fcontractors)r1 d p nr m.the
cot t e, Idem. a 204 - -UNDERFLOOR, FRAME
such projects w r /
❑lam exempt under Sec. ,B&PCfor this aason 205 - UNDERFLOORS INSULATION
° oat" 301 - ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION —
Iherehyaffirmoncer penalty ofpe'sayone nfmpFollowing declarationx 302 TUB & OR SHOWER /fix
303 ROUGH MECHANICAL
❑ 1 have and will maintain a Cendiicim of Consent to self-insure for worker
Compensation. as pmvidrA for by Section .3700 of the Labor code, ror-the 304 - ROUGH ELECTRICAL
•peffan rine of the walk for which this permii is issued. 305 - FRAME _
" 01 have and will maintain workers compempfion msaranee;as required by section 3 0 6 - HOEDOWNS
3]00 of the Labor Cade,for the performance of the work far which this'mid is
issued,My Worker's Com 307 - INSULATION
Y Compensation n Incur c 'ser and Policy
bel arc.
rr . .. - .. . . _..__.-
0 06d
CumrCERTIFICATIONOF EXEMCy No.:I'I'[ON FROM/W WORKERS' 0�4� L�s t- 30.8,-, s.SHEETROCK i;",,• , - - -- - - -
COMPENSATION INSURANCE 3 0 9 EXTERIOR -LATH-
.,- . . .._.-..- -. .. .-.. ------ ....- --
310 INTERIOR LATH
. (Tn.sea on need not a completed inhe permit is for one hundred dollars - .
stool leas.f 311 - SCRATCH COAT
Iearly mn i nelson it of kr n'n.n x Y 'saea:I - 313` - ROOF NAIL -
sou t ply yp .o - any e n11.Iscom b""q'he Wmlwr, 501 - FINAL ELECTRICAL ENERGY
Compensation Lawn of California.Da¢ -
NOTICn, 502- - FINAL PLUMBING ;ENERGY
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should
Z IweamesubjectmmeWmrkeraCmnpensatmnproyisimm;ofheLabor CodeyWmust 503 - FINAL MECHANICAL ENERGY
C forthwith comply with h provisions o this permit shall he deemed revoked.
z - - 504 - -FINAL-BUILDING -ENERGY
_ix rn _ - CONSTRLCI3oNLBNoIIQcnc[NCY 505 - FINAL ELECTRICAL -
I hereby affirm that(her t.a constructionI ting ug y f theperformance
,W '� of
work for which his peCuti issued(Sec 3W7,Cis . 506 . - GAS TEST .-
.Le
Le d r s Name ..- .. - . . .. .. .. .... . .
y �
U C me"'anddr`ss 507 - FINAL PLUMBING
(certify that i have
read'his application and nme that the above inrmmadon is 508 - FINAL MECHANICAL
F" 'C—r.1 all to comply,whh all city ani c°tiny mdinames,and ,are law.relating
' , 5 0 9 - FINAL GRADE
, re nsw
� U • building Covion,and hereby-authorice representatives of this city to enter upon
p theaboye-mentmpedpropertyformspciiou mW.as. 510 - FINAL PLANNING
- E.t d M'el ugrm rm save,indemnify ani keep harmless upenino a ain't juJgmenB,costs and expenses me way oceme ago sale 514 - FINAL PUBLIC WORKS
V Z Con
iy in csequence or the grunting of mi it m a
APPLICANT UNDERSTANDS' >WI ,COAt wITH A NON-POINT '
SOURCE'REGULATIONS.. Issued by: Date
Signature,of APplica ccontractor easeRe-roofs
HAZARDOUS,MArER1ALS DISCLOSURE"'
n
Will the applicant or future building occupant store as hardle harardom moscoul
Type Of Roof
0,Jefmcd by the Cupertino Municipal Code Chapter 9.12,and the Health and Safety;
code.Section155J_tl -:
All roofs.shal] be inspected prior to-any-roofing material being.installed----
Wit the up,licart or future Wldnga pa t use equipmento deviceswhich! If a roof is iMiAlled without first obtaining an inspection;I agree to remove
cm t ha re a ono nes ns dc�4J'^ Bay A ca n Quality hlanag o
. i".°toy
Dall new materials for inspection. Applicant.,
understands and will comply with
all non-pomi source regulations..
1 have read the ou,schir,mar c urafter r 6.95 of the
Ca1Jom a Health&Safe Cod Sect, n 3 and 25534Fund stand that
fifth b Idgdenol ly have t 'his ii' yr<ponsblt t ructifY the -
ruc win of th q 'r at. h c ust t 'i,s.a nc f Certificate of
s pans. Signature of Applicant Date _
Owner,or nothosiaed agent Date All roof coverings to be Class "B"or better
OFFICE -.