00050186CITY of corERrlrlo
-PN RACTOR )INFORMATION
BUILDING DIVISION PERMIT
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BUILDINGADDR ... _f3LVU-
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PERMIT NO...MIS
OWNER'S NA NTER AS
OCIRT
APPLICATION SUB DV"So
IPHONE: -
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SANITARY NO.` O ¢'
ARCHI'I'E.CT/ENGINY.ER -
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BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH -
~ LICENSED CONTRACTOR'S DECLARATION
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Job DCSCIlpt70n
I worth, nn mat Into de
licensed unr pmvlslon, of Chtipter 9leummmmcing
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with Section )OOT) of Do slon 3 of nia Bivslnnss and Profession, Ordained my Brame
"m full force and effect.
License Cl... Lie,M
Date Contractor
' - ARCHITECT' S DECLARATION
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understand my plans shall be used as public records
'COMMERICIAL CELL SITE
Licensed professional" -
OWNER -BUILDER DECLARATION'
I heaehy affirm that loon exempt from the Contractor'., License Law for Oto
following reason. (Semon 7O3L5. Husiness and Professions Cale: Any city or county
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1 which oormors a permit m cnnxtruct. alter, imp rove• demolish, or TopaiT any strucmm
prier m it isamance•m,o oNdres the applieant for such permit to filensigned smteomnt
S 'I!t. lwrArea Ya1naL70n'
'hut he is licenced pummmt in the provisions of the Comraomr's Limmic Law (Couple' 9
(commencing with Section 7000) of Division 3 of the Bashed, and Professions Code)
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or that he is escort therefrom and the basis for the olleged oxomptloa. Any vlolatirn
of Section 7031.5 by mnyapplicant for a permit subjects the applicant to a civil penalty
of not more aIran fisc, hundred dollars ($510),
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< Allt�l�I bff35. 0 Occupancy Type
❑I of the p I y employees with wages 'm rsaian
t
�ny,
u the fle 're offered or 1
Bit Presa�, Code:The ce i Lr,ir,c dolod a, a t ap,1y
Require Ind Dations '
yr (if property Who burlds or improves thereon, and who1 h Irk himself
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through h: ply provided tlat.ch rip a t i intended or
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offered f IT h hetmild g 'mP t solid withinyear of
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Io plt to Trrwill have thburden of provingtntl did not buildor
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101 — FOUNDATION
npro,e for purpose
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f 02 PIER-
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fie property, alt, ly ar u y 0 licensedcontractorsto
con,dructte (Sec, 9044, Buslooll old Pn r :' s Code )The C
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103
project meds
— UFER
- L e of apply men owProperty who b e on,rovrthrown
and n t. Int swab projects with , ret nmicA pursuant m the
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i. 04' — RE'BA R
Contractor License Law.
❑mpt
Taro exetinder Son. '_ `,BffiPCfor this reason
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ANCHOR BOLTS
Owner Dater
WORKER'S
14t6 — SEWER & WATER,'
COMPENSA'I']ON DECLARATION
2012, — UNDERFLOOR PLLIMHING
'203
Ih my a Berth. lay rperlaryrm orisf the gdalrro:"-
❑ I h A 'll w C off t f i t f Workers
— UNDERFLOOR 'MECHANIC�_� '
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nope: r as p e I r by ti ct rn nen or m I n calci f u
3 L.
p r of the kIwhichthi. permt d.
204 UNDERFLOOR FRAME�y%.--� "
205 -' IJNDERFI_OOR" INSlJLATION
° I hok nA will u i W k: C p w a To nncc t 9 A by 5 tion
3700 f theLabor Coal f theperformance of the k f which thispermit is
.301 iir i .(.
_ — ROUGH PLUMB"IN[�_'
issued. Mr werkarae penin on rosecnsiar one Policyn}amnerare�
- 302 — .TUB & OR ^4HOlAlER
Ca tar. Policy N .
I neon Q Ar. ����•
303.— ROUGH MEC NTLI {� ,
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• 304. — ROUGH EL..EC
CERTIFICATION OF EXEMPT ION FROM WORKERS' -
COMPENSATION INSURANCE.
(TIaction ado the plea rfm pe , : r n hundred d ria:
•(sl(.o ole.)•306..
.- 305• — FRAME
HOLDOWRIS
1 elf tear the of of kf I 1 m tin t i. to ed, I
ce n t employ any p" r ria m nacre e di m the w keo
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307 — INSULATION
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QmpaO i Lax fC 1 Date
Applicant
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308 SHEETROCKNOTICETOAP'I •,
T If ft k C fiExempmn
at of you:bald
br oro itotheW Compensation tyleromost
p
309 EXTERIOR^
forthwithLATH spaply with such pro,'v'nnc or mv permit shall be deemed
rovokad.
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310 LATH
CONSc,c in aION LENm NG AGENCY
II by
th ih me i leading ng yfx the perfnr ane
�.Pel(s
, 31=1 '^ ' -
SCRATCH
SCRATCH COAT
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•oenA N for Ir I m pent i', vl9zcxc)
.31'3- — ROOF NAIL. •.
"A Address
Ic�tifyhatih informmmn
S01 —FINAL ELECTRICAL ENERGY "
arced ahisnppl'tilon and smiethm thehve is
correct. 1 agree to crony with an city and county ordinances and mate laws slating
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502 -'. FINAL PLUMBING ENERGY
to building construction, and hereby authorize represemanves of this city enter upon
,heanrse-mendenedprepeoymrmxprchrnpurposes.
ify
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503 — FINAL MECHANICAL. ENERGY.
(W)agree h> save.' 1 anAk ph bless the City, of Cupertino against
llanlb: Iudgnenix, t— 1 xpe n ay nano y' a against aid
504 —. FINAL "BLIII_DING ENERGY
car/ c fin g rt per
-APPLICA IN R tNOS ILL MP ITIi ALL ON.POINT
APPL, F ATIONS
SOS -ELECTRICAL.—�
Issued by:' Date
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9igants A,rphcant/ent.i .. - - - Date
HAZARDOUS MATERIALS DISCLOSURE:
Re -roofs =507' - FINAL PLUMBING.
Will the t eapprc It ewmmgacupantcore orIndlemarchaonarial
as darned by the Caperton Municipal Code Chapter 9,12. auction Health and Safety
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Type ofRo�08'FINAL MECHANIC
Gude, Samron 25532(a)/
❑sen °"°
will the appRvart or future handing ovenpadt axe io,opment aT devices which
9 F IBL
All roofs sl; ms gc(� Tor xn, oofigg material mein installed." -
IIggss
If a roof is ed wlthb rct �hY v�ii[7nspec[ion, I agree to remove
emit hazardous an cmdvnarrnn as Defined by the Bay Arca Air Quality Mamgmnant
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all new mat8t' fdr'i�� Lei i . tCJdbuAdGR98,g anri will comply with
all non- t, urce"regulatio y
1 have boad ih lancrodear, materials y t. under Cherie r 6.95 of then
California Heril, &Satc'yCode, 5 id . 25505 25533 d25534 1 understandth t
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fthe building does not cut reallyh tenant. that . ity pm11tYi only the
oc pant of the reyuir nts which m w h a prior mis'uacu ncnI Cen forte of
urpaeay. .-
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Signature of Applicant Date -
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All roof coverings to be Class "B" or better
Owner oraamorined agent .Dam
OFFICE - -