01020055- CITY OF CUPERTINO
CONTRACTOR INFORMATION-. j
BUILDING DIVISION, .. PERMIT
BUILDING ADDRESS -
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PERMIT NODEXTER
D�
01020055..
OWNEWS NAMII
APPLICATION SUB DATE
02/13/2001.'
PHONE: HAMBERLAIN PA-
SANITARY NO. CONTROL NO.
a
ARCIII'IFGT/F.NGINEER:
BUILDING PERMIT INFO -'
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BLDG ELECTPLUMV� MIiCH
LICENSED COM1TRAC10R'S DECLARATION
]Ob DCSCOptIOn '
Ih hyaffirma rI z a licensed and,, P , of chaffer 9 (roolormacia,
witht cl nJf)(go tD 3 ill Bu aal I'aeiom Cnde,mdmylemnse
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v i fall force wad effect GI N
GAS LINE/FIIR(/EEPPLLLAA7CE INSERT
Dale v n.""`
o
ARCHn iCT'S UGCL
1 uneanhnd my plans shall be ,�rJ as u s rvn
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Lic J . annal-
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OWNER -BUILDER D{ CLARATIOh
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b
1 1 eras) that11. p, brands, ,h C , t L La for the
toll . (Se remmy-
(Section ]InlS H. -m tall f IaCode ,An,
r npuu any .truants
a v, dv n li t rkin
wh 1 y a permitl
res the ppli fa it it
priortons issuance, also requires thevokornt stmemem
su
Sy. F[. Floor Area
Valuation
o firm?, LGlnssignet
tie, Confirm?,
mated iahcemeepmsaam tome prooa,m nr ma
ImLow (Chaptm9
the Bisorsland Cade)
3 of mldnrba mm trot
will, 8cunao 9nt)and
aammlot
f re basis
mercrm,n and nap bavia ire . any vimm6m
k i, ex n, vi
o, mm he m es1.5
$ 1
of snrnon b any objects he I nI i
11 sate a pennh sabj«ts me avvheam m a dvil Penalty
APN Number
Occupancy Type
or fol nnoa Iran live nttnered eauant ($sw).
a Inas iv dard.d
❑ 1, as owner of the properly; or my employees with wages as their sole compensation,
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:Required Inspections
will do ,he work, and the structure in not intended or offered for sale Dec. dJ.
Busines.v and Profession. Cafe: The Contractor. iLaw saes not apply to air
w r of property Who builJ.r or ifituaves mason, unit who does such work ancocif
r to nyh his awn employees. prosasled that such improvements are not intended ar
204 = UNDERFLOOR FRAME
f= sale. IL however. the building o, imprn,emem is sold within are year of
eomplitnenwmt-hnilderwinitmnthebrocnnfprthathedidmiIhol`t's`
301. .. ROUGH' PI-.UMIdTNG -
ian"'vcforImpnaeol'afe.).
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303 — ROUGH MECHANICAL
❑L sowner armro
appnr.amexclusively connecting with licensed comments t„
the Inti,a, (Set. 7WL Bnaiaeas sol Professions Cnnao The Camrana,'a
, Spit} — ROUGH ELECTRICAL '
ianom
ncense Law doe,not apply to annwna,ar ptopany, who build, or improves forest,
and who contracts for such projects with a cunnicam.a1 licensed potation to ,he
505 — FINAL ELECTRICAL
Comaeesernu en,e Law.
C l or exam umdcr Sec . B & 1' C fonbi, mason
507 — FINAL PLUMB I NEs .
Owner Date
508 — FINAL MECHANICAL
WORKER'S COMPENSATION DECLARATION
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514 - FINAL PUDLIC'WORKS
I hereby affirm under wreilly of Inip, one of the following deefoream s:
❑ 1 have trod will maintain n Certificate of Consent to sell'-insnre for Worker's"
Cnmpcnsuion, Its Provided for by Section 3700 of the Labor Cale., for the
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Permanumec of the wank for which this permit is issued.
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El ha,a J off mannin Avak,, , C peroadion I n hired hy5 Ilan
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3900 f II Lae l' d f thp I mm 1 th k f 1' h Nis permit is
ifm Ins,
sued
IIkJ^is��Poli
r•.,
N/ s
y N
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CERTIFICATION OF F.XEMPrON FROM WORKERS'
' COMPENSATION INSURANCE
(I his seat a need ran be conaplEtcd it ate permit is to one hundred imimra
I certify thus is theperm ,maned onbe work rce which this pernd_I Is insuaL I
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shall not employ any person in any manner sit as m become subject to the Workers'
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Compensation laws of California. Dare
Applicant
NOTIC)i T'DAPPLICANTI II, of ra making His C"Idic-ate of Exmuprat, you should
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becuras mirjecno the Wdrkera Compensation prvo,kiomof the Lubar Cudc, you muat
forthwith comply with such provision onhis lw.air shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I wra by affirm that there is a construction lending agency for the penumbra"
of the work far which chi, Permit is issued (Set. 3191. Civ, C.)
Lender's Name
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Leader's Address
I certify that I have read div application and state that the ahwe information is
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combat.I agree Iu comply with all city and unnny anfiam"cl and etme laws relating
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lo building enngrvnion, road hemny nulhon,e mpresentutivcs of ,hi, city u, crier upon
the t. c i net property for inspectionpurposes
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DVc) agreeats nln'fy and keep it less the City of Cupafno against
liabilities, 'j dg ns, t I xp uses I unauW_waY.t setae ago a add
City' q O ord g r t
APPLILA NO IDWILLCOMPLYWITH ALL NON -POINT
lssuedb l0// Date
SOU RF NS,Y•
l/
me of Applicmalcnmractnr Date
' Re -roofs
HAZARDOUS MATERIAI S DISCLOSURE
Will the applicant or tome budding warrant stare or handle anomalous amtmlal
Type Of Roof
as deft al by 0o Cuponinn Municipal Coda, Chadaa 9.12. and the Health unit Safety
Cafe. Section 25532(x)'!
1:1 Yes ❑No
All roofs shall be inspected prior to any roofing material being installed:
.Will the applicant ormorebuilding occapanta,cequipment (it devices wmcla
If a roof is installed without first obtaining an inspection, I agree •to remove
omit hazardoux air amtaminame as defunct by the Bay Area Air Quality Mdm,anaen,
District^
all new materials for inspection. Applicant.understands and will comply with
DYc` El No
all non -point source regulations:
have read Bra h omahm, materials ,eyuircmems under Chapter 495 or he
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Culifomia Ilealm & Safety Cod, Senium 25501 and 25534, 1 mull that
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ifthe bu'JJingdoevnoccormnlylo, tenant. Ihul' ti t¢y �itibllay to notify the
cupant of the rcyuirement which must nor lin issuance of a Cenilicete of
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° <°°'°`y'
Signature of Applicant Date
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All roof coverings to be Class "B" or better '
ora „ed agent • - .Dale
" OFFICE .