00070173 CITY U10N�cUPERTNPERMIT NO CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMnNO.
OWNER'S NAME: APPLICATION SUB LAI'E
0
PHONE: SANITARY NO. CONTROL NO.
❑aeY ARCHITECT'/ENGINEER: - BUILDING PERMIT INFO
�i❑ x BLDG ELECT PLUMB MECH
Oc 6 UN L� L_ I-1
5 y L I hereby II LICENSED CONTRACTOR'S DECLARATION 10b Description
,
O Z_ y n'inn pnrvhions of Chapter 9 0.omn..aviag
F=C with Section 700111 of Division 3ofthe Business uneV be,;om Code,midway license -
6aC
is in full line]and eflml.
C 6License Clas hie.#
Kowa Date Cantmem ADDITION OF 702 SG!. FT. GARAGE
ARCHI IEC'S DECLARATION
O g I understand at,plan,shall be used a,public]mrd
r
w—O 30 LicensedI`rnfcssional
OWNIiR-BUILDER DECLARATION /
nad= I hereby vm um ucm"i rdnn Wpt from Ire Cnnrrncinris Litcnec Law for the ,Or
(r 3< following mason.Lcrou 1 nDLS,Iluslnesv oma limfensnns C000:Any city nrcnnnry
ae F O which it,I..n a permit m enmwa•ulmq improve.Jemmish,or repair any aoxnare
m1emma Q
i C3Q pro«,o its issuance,also reyuienhc applican,6r tachprnniuo fileasigned ntmement
thio h<isli«nsnl pursuannn me pnwi.ions of the Cnnvanu/s License lawlCTapter9 Sq. Ft. Floor A ea Valuation '
(commencing with Section 7IX(p of 1hekion 3 of rhe Business and Professions Code)
either he is exempt therefrom mid the M1ais for me alleged exemption.Any violation -
ofSectlnn711 by any upplld 11 lint apannit sunjecta me npplicam mucivil pcnuhy
0
1 ata door neoaorta eouumasno). APN Number � Occupancy Type
r ask,,]ad the structure
is oyee tended ages cried f ride ed.70th, r
ewPro and the xmucme is not cho',i i oroffered forwot(Sec. to anane Professions code:Tbc roves thereo Liccme law does tan apply to an Required Inspections
Who builds or improves thereon,and who Jces such stork himself
o"through his own employee,provide]thio such impow,amed,are mit intended or 101 — FOUNDATION
offered for ole.It,nnwever,the building or improvement Is sold wtmin nuc year of
ampledon,thenwner-milder w alhavame burdenol"pmving tom It,did Opt hiiild or 102 — PIERS
improve lirz purpose of salt.).
01,as owner of the property.am exclusively contracting with licensed contractors to 103' — UFER
construct the pmjm(Sm.70 .Business and Professions CaeeJ.Tne Contractors 104 — REBRR
License Law does not apply to an owner of property who builds or improves thereon, '
and who nmtmms for such projecls with a emntnaorfs)licensed pncwma m the 105 — ANCHOR BOLTS
cntimmorxLi<en.e w. 1.06 — SEWER &• WATER
_ ❑len exec lacier c.—.B&PCfnr Ibis rcaso — .
W Date 202 UNDERFLOOR PLUMBING
WORKER'S MPI°NSATIONDECLARATION 217,13 — UNDERFLOOR MECHANICAL
Inernny alarm enact baby of perjury one OF the rnnnwmg declarations: 204 — UNDERFLOOR FRAME
I brave ;rand win mdnwin a Ce,mexate of Consent a,self-in,ure to,W akcr's
'n I lersaioe, a, provmed I ray section 3701) rit ore Labor Code, ft,r are 205 — UNDERFLOOR INSULATION
performance of me work for which this permit is issued..
301 — ROUGH PLUMBING
❑1 have and will maintain or the
Performance
Of t eworkf as which
this
by Section
3700lir me Labor coon,for me petfamnncee in cr work for numb rids permit is 302 — TUB & OR SHOWER
wed.SlyWorker's enmpn nnmwmmeem erandPnheynarmbera`' 303 — ROUGH MECHANICAL_
Carrier: Polley No -
CERTIFICATIONOFCXEMPI'ION FROM WORKERS' 304 ROUGH ELECTRICAL
COMPENSATION INSURANCE 305 — FRAME
('this..tion need not be eimplaeJ if the permit in for one hundred dollars 306 — HOLDOWNS -
(SI00)tar IessJ
1 certify that in the perfnnmaec of the work for which this permit is issued,1 307 — INSULATION
shall not employ any Igmmr in ally onion,au a,m haemo].Object m me WnrkerC' 308 — SHEETROCK --
Connpenwi me Laws if Californbt,Date
ApNicam 309 — EXTERIOR LATH
NOTICE TO APPLICANT:If,aloe,making,bs Certificate of Exemption,you should
Z become subject it)the Worker's Crou,samation provisions ofthe Labor Code.you most 31.0 — INTERIOR LATH
zQ Q mal with comply with such pro,kims.o,,his permit shall be J«mW revoked.
CONSTRUCTION LEN61NC.AGENCY 311 — SCRATCH COAT
04I brach,mrlmn thio there i,O amstmcdoo lemling agency(a,oAam
re ped 31.3 ROOF NAIL
of the wmk Out which this perm ll is inwW(See.3097,Cls,C.)
ZLeneer'SName 501 — FINAL ELECTRICAL ENERGY
Isadcr's Address -
U Q .1 cnifythutlha mad this aWhertionandstatethattheabove I maintaine. ed�
502 — FINAL PLUMBING ENERGY
f+s•F. correct.I agree to comply with all city and..all cohnitim,and state laws elating503 — FINAL MECHANICAL ENERGY
Q U to building cnnsmteion,and hereby authorize mpresentatives ofthis city to en ter upon
yF w meabove-t«nhtmedpmpenyfor hispee;onpur,i 504 — FINAL BUILDING ENERGY
L We)noted to save,indronify and keep harmless the City of Cupertino against .I
LI) liabilities,judgments,mos and erases which may in day way ammo.,.an,,said505 — FINAL ELECTR I CRL
U Z City in mn.wyucnc''=ran'
grantin u his permit.SOURICCANT EONO REGULATIONSNDS LL 'OMPLYWITHALLNON-POINT : SQ16 — GAS TEST Dale
bi OF Fill
Yc li)rs _rxRIAls0lsc.osudDate Re-rooSignmur fAppoH
508 .— FINAL MECHANICAL
%11 the applic m future handing icenpnnt"are it handle haramluu,amted'al 'type of Roof,
as deffanl by me en nen Mamieipal C«b,cnaper d.Iz.dad me Hemm ane samrr 509 — FINAL GRADE
Code,Sectlnn 255. bd? yp .
0Ye% ONO All roofs shall h71il�c ectef r,,A6:�nfy_R�1 �terial beim installed.
W;Ilth pplicmttorfuture building Occupant use equipment ordevices which If a roof is insta�lJAvifhot� -AP&htzRii}r 4a; - s�11Wg, agree toremove
emit hazarJto n r conmminann,as defined by the e:ry Arca Art Quality Management
District? oN - all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
I he c read the hazardous materials mrlriremnns under Chapter b.95 bf,he
California didlb&Safety Colo Sections 25505.25533 and 25574.1 understand that
lL/ if the building Aces not currently have a anam,that i,is my responsibility to notify the
Occupant of the requimarenu which mus,be met prior to issuance of a Ceniticae of
D"apaa`, Signature of Applicant Date
Oxine or ambm;md agent Dam All roof coverings to be Class "B" or better
'OFFICE '