01060081 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10101 N DE ANZA BLVD ASSOCIATED CONTRACTORS C RP01060081
OWNER'S NAME: APPLICATION SUR DATE
r r• FIDELITY FEDERAL BANK 840 JURY CT 06/13/2001
PHONE: SANITARY NO. CONTROL NO.
\. 4089771400
w O O ARCHITECDENGINEF-R: BUILDING PERMIT INFO
z BLDG ELECT PLUMB MECH
y Zai C.J L" I IJ L-1
z N z LICENSEDCOsITRACTOR'S DECLARATION JOb Description
O Z—p I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing P
f,ht_w withSection]WO)ofDivision3aftheBusinessand—Profession,CCmk.andmylicense TENANT IMPROVEMENT. (4TH FL. )
z x x a is in full force and Cf(�t. Lic.p T 01 Z
S rap d to Dole Clan - GLQ rs
tWe 3 L Dom C Canmae°r
A CH'TECT'S DECLARATION
N°,g Iunaectt my Rt ITe alfa at,mhrc ommd,
ce Y
u S.00 Licensed Professional
w-V . OWNER BUILDER DECLARATION
so 1 hereby affirm that I am exempt from the Contractor's License Law for the
t_Z a following recon.(Section 7031.5.Business and Professions Codc:Any city or county $200000
zF 0 which requires.a permit to consione,alter,improve,demolish.or repair any somemrc
i3" pn r l I 9 the applicantf hPermitto fl .tW statement
' tth
ihaih sl' Selp mwm provisions rn C to oe I 1 (Chapter9 iv -� .oyq f L 1"i Val�la�l Ull
lu g 'Ih Sci ]OW)rfU vil B: d I( rus'ots Code)
or that he is eaempt therefrom and the basis for the alleged exemption.Any violation
of not more
v any hundred
dollars
ofora permit sublet¢the applicant m a civil penalty _ pp�����p� Oc Type
of not mor=than me op erta r my a(ploy). 10 lAPN 1'' 3ftAT I ON
❑I,as owner of the nd the s,ru my employees with wages fe their sole le(S compensation.70cit. 4:02 PiERS
will do the work,-and thestructureis not intended or offered for sale(Sea]Oda,'
Business and Professiom Code:The Contractor s License Law does not apply to an 103 — UFER Required Insp t • s
owner of pmpeny Who Wilds or improves thereon,and who does such work himself
or mmtigh his own employees.provided that torn improvements are not intended or .. ... _ 10 4... REBAR I
bf@rtd for tole.IL edwcvcr.rhe nr;ilJinsold
g m radem itam s at he din one Wild of _
completion.rhe owner-Wilacd will have rhe When of pmving that hedid not build or 105 — ANCHOR BOLTS
improve for propose ur tale). 106 - SEWER & WATER
01 herorthe p(SecnramBcluse 1r contracting 'InbciTheContracttm' 202 - UNDERFLOOR PLUMBING
un r cl the protect(Sec.]Oda,Ba.t;ne.:and ProR.s.ons Cudc:)The Contractor s '
caicLawdoesnotapplytoanowarofpropertywhoWildsorimprovesineeeon. 203 - UNDERFLOOR MECHANICAL
. dna who contracts for:urn pdulects.w m onvaa tt:J r«ntea,pursuant.m.ma .. 2 04... - UNDERFLOOR...FRAME . . _._.
_.
Conpaaoct Licence Law. -
-
J ❑Iamexemptundersec ` " ^",B&PCto., his«awn 205 - UNDERFLOORI•INSULATION
°w " °a1 301 - ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION
I hereby arum crane - 302 - TUB & OR SHOWER
penanr ar P�dury aro often following aetlataaant: 303 - ROUGH MECHANICAL
.�
01 neve and will maintain a CeniBc m of eontem to self insure for Worker's 3 04 - ROUGH ELECTRICAL
Compensation. as provided for by Section 3]00-of the Labor Code, for me
pedbrmance of be work for which[his pe.it is issued. 305 - FRAME _
WI have and will maintain Worker's Compcmatmn Iniumnce,as required by Section 3 06 - HOLDOWNS
37M of the Labor Cade,for rhe performance of me work for which'mis perms[is
issued.S Workers Compeasaliocarrier307 - _INSULATIONn Insurance carrier and Policy number art:
, .CERTIFICATION OF EXEMPTION FROMWORKE309..RS: `
Ga i+I� F 1 S+1- y SHEETROCK
',Policy 00001obg308
COMPENSATION INSURANCE
EXTERIOR LATH '
` t
INTER ,.._...--- _ - - -
-"rlhit section heed not W completed Irma aan:r�t far ane hundred daunt, 310 ., IOR LATH1 � � ., .. . '
Ip"gnarleta.' 311 - SCRATCH COAT
It nfy that iii th perrtm ran kr n nhis
peml ::ilea.1. . .313'_=..ROOF- NAIL.
shall notemploy any.Pe n y a asviberom bjce1.rheWorkers 501 - FINAL ELECTRICAL-ENERGY
Cl pc. poo Laws of C I f Date .
Applicant.'
- -502 --FINAL- PLUMBING -ENERGY—
NO I ICE DO APPLICANT If art making rh C nifeate al bxe pf you should .....
Z become subject to the Wk Compensation provisions of thLabor Code.ydamust 503 - FINAL MECHANICAL ENERGY
fort the 'ply with such Provisions this a tshallb deemed ked.
z O 504- - - FINAL-BUILDING--ENERGY- -- - --
here
-- _.. ...
CONSTRUs a emou ENDINGAGENCY ' 505 - FINAL ELECTRICAL,
e 1 nercby affil-mat mere its conamaio, lending agency forme perPormance
"anne work roe wn:rn Imt pit or itrt�ed Ilea.3os].civ.c.) 5 0 6 - GAS TEST
r is Name.. :,� _.. .: � ._ _ .. -. ._. _�.__. . .
dQ Londe _
Z "Ade '" 507 - FINAL PLUMBING
I certify hot Ihave mail this application and state that the aWve information;t' 508 - FINAL MECHANICAL
correct.1 agree to comply with a0 cityand county oramanmt dna trate law.,"Intirg 509 — FINAL GRADE
t.7 'to building como.eion.and hereby authorize reprcse this city menmru
meaWve"meraaneJproanyrarmtpmnaneparya. 510 - FINAL PLANNING
Ca (wQ agme t°mvq indamnilY"v d pour u Cupemnoagaira
m liabilities.ludgmemt.raw,and expenses ;th par' eagaintttaia 514 - FINAL PUBLIC WORKS
U Z City In consequence of the Starring or th' r is cm
r SOURCE REGU ATIOONSAPPLICANT UNDERSTNDS Dw � AMPLY WI ,L NON-POINT Issued by: Date
HAAZARDOU
. 'Sgnamrearnppra ZARDOU S MATERIALS DISCLOSURE Re-roofs
Will the a Luper[v,fum're Wddina ie.CWm store rr hamlk h earn a Safety
as defined b m c Type of Roof
y pert no hl n<pl 1 Ch pr 9,12 rJtl Hearn JS fry -""
Cud 5 ton 2553 1'1 r - t 1 "i"r a c 1 ) v
All roofs shall.be.ms ected rior..to an roofing material being
P, P Y g g installed.
Will m applicant future b Id Sac p t use equipment devices ton n If a roof is installed without first obtaining an Inspection, I artree to remove
Chinic d ora etas Jef db)thBay ArtaA Q fry hlar"p m c,
°i" 'ove all new materials for Inspection. Applicant understands and will comply,with
all non-point source regulations,.
I have read the hot Taous materials is cader Chapter 6.95 of the
Calif r a Health 2 Safety _5505.3 _
if the building does nor in fiaveB
cit ism ¢:ponsihi lily to non ry the .. .
occupant pf the tc
Occupancy.
an yuireme hirn'in once of Cenidcate of "- -
mei Dista
... panty:
—.. Signature of Applicant Date
" ow^erne a^mo =ea age^[ Date All roof coverings to be Class "B" or better
. . . . OFFICE . .