00080022 CITY OF CUPERTINO
BUILDING DlvtstoN PERMIT CONTRACTOR INFORMATION:
tlU1LDING ADDRESS. )'rRm„Nr^
Dw'ER''"69 HEATHERWOOD DR nPPI,ICA'l' �SJ>��22
,ONE: COLLOTON - SANITARY.tiP/05/[ilbll'WII NO.
VVJJ CC CCJJ �� O
C IIIIN
j2 0❑z ARCHITf:CT/F.NGINEER: - ULIK BUILDINGPERMIT ELECT PLUMB MECH
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LICENSED CONTRunder prDECLARATION Job Description
z H O 1 hercny afti,m that I ran ofthelicensed under provisions of ns Code.(commencing
with fall 7000)of andefect. anJofahe Easiness and Pro&ssionsCWaand my license
4,77 is in full force and effect.
s 6
eds-o aO U< uClasp
[)are Co
ARCHII FC-CS DEC
LArRATION _ ADDITION
I ndea n nay plans ndl be
-
as puhl'c accord,
a.Eac Li II I al UW N1RBDlS
�' 1 DIRDrI,I ARATION -
m_ I h rrby til that I a m ,ilic C t a . License Law for the -
C fill w 6 (Se0i 17031,.5. itoine,and I re, n.C d Any e'ty r munry
f ❑ sluch nq, s:a Pun[lonno ulaq'npsvcdanlh.,r u.paranr sanctum Y
��� Prinr,n itx isxuunca oho mquiren tic iq,plleam lornuen Permit n,nleasigned sueenrem - .
h,athe is licensed punto,nt to the pmvixions of the Contractors License Law(enaaar9
mom„enemg with'e”i70gnofDmiaima3onlm
eeslnessaaeProfession,Code) Sq, Fl. Floor Area Vnluati
m that he Is exe apt,nncfnnn mel the fasts for me alleged exemption.Any virlrno
of Section 7031.5 by any applicant for a pemdt subjects the applicant to a civil penalty �� p
of nm more man nae hundred dollars S501)1. APN Number
❑I,mnwnnr of the PmpertY,nr mY employees with wages as their sole compen. on
will do the work,end the awcturc is nor intended or offered for sale IS 71}14,
Business and Pro essionx Crede:The Contractor s License Law aaex nota v 359,6059. &quired Inspections
caner of property N'ha huilAs nr improves thereon,and who Jrm such work bin
or mmugh his own employees,provided that mcb impnnzmemx arc not intended or
offered for sale.IL however,the building or improvement is sold x ithin one year of
ampletion,meowar,haiiderwiubase the human afpmvingthat
hedid a.Read or 101 _ FOUNDATION
improv purpose o
owneruf thepropeny,am exclusively contracting wise licensed contractors 10 102 PIERS
construct the project(Sec.7044,Business and Professions Cmle:)The Contractor's 103 — UFE R
License Law docs no,apply m an owner of property who builds of improves thereon,
and no contracts for such ptsaws with a commercials)licensee pursuant to,he 104 — REBAR
Cnmrectors Llcem,Law.
❑I am exempt under See._ ,B&P C far this reaant 105 — ANCHOR BOLTS
�'�4'Od 106 — SEWER & WATER
UNt.'C)MYENSUECLARAI'[ON
202 — UNDERFLOOR PLUMBING
Ie ad will pen:mynrperjntytimesnttohe selwimgae-for or 203 — UNDERFLOOR MECHANICAL
C hove and will maintain a Cenit tents of Consent 0o se Labor Code Worker's
Comprna,tim,, is provided nd by seorail non of me Lamar coca, for me 204 — UNDERFLOOR FRAME
perfmt„anreonl,e work ser wnmWl,nits permit is leased. 205 — UNDERFLOOR INSULATION
Ell naw:me will n,;dnmln Workers Compensation Insurancx,as required by Sec,inn
37011 of the Lahar Coda,I'or the perfonnmnce of rhe wink for which this permit is 301 - ROUGH PLUMBING
ivaard.My W..kcr',Cornpar,rli m
i m,unce carrier and PnGcy number°re'- 302 TUB d• OR SHOWER
canief: CER nncrclIONOFEXEMPTIONFROM WORKERS' 303 — ROUGH MECHANICAL
COMPENSATION INSURANCE. 304 = ROUGH ELECTRICAL
(I his section need ao,he completed if me permit is fa,one launched donors 305 FRAME
1suwl or lona
I anifr that in the performance of the work for which this permit is issued,I 306 — HOLDOWNS
hall a,,(e
t employ a,p ram in any mto m
unne, ,,as hecae mbjer,as he Workers 307 — INSULATION
Compensation Laws of California,Data
Applicant 308 — SHF_ETROCK
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you shoulJ
Z becomesabjttunthcWmkee,Cnmpemsa0iunprovsionsonhelrMrcode,You ma” 309 — EXTERIOR LATH
0 o forthxithcomply with such provisions or[his Permitshall bedeemed mcoked. 310 — INTERIOR LATH
F t CONSTRUCTION LENDING AGENCY
mIhereby alRm,that them isaconstruction lending agency for the Performance 311 — SCRATCH COAT
of the work for which this permit is issued(Sec.3097,Civ.C.)
M Lender.Name 313 — ROOF NAIL
z Lender's 1maltyt 501 — FINAL ELECTRICAL ENERGY
V I certify thin I have rend this city
and on and state that the above in6emmiati is
kt F cmren.1 acme in crrnedy with all city and county ordinances and state laws relating 502 — FINAL PLUMBING ENERGY
O J thekhoie-construction,andnereinspecmrereposenaativeaanninaiayaoemterepn" 503 — FINAL MECHANICAL ,ENERGY
alts above-rnemioned Dn,Pmy for inspersion purposes.
F ped, (We)agree to save,Indemnify and keep hornless the City of Cupenino against
tn m,nddies,judgment.,costs and expense,which may in any way accroe against said X04 —
FINAL BUILDING ENERGY
C„) Z City in con,que,1eonne glamilmal this pennies
'so alce"T uuT I"," sA'Dwl. LNrLYwRH^ALL N-PD _ Issued by. .505 — FINAL ELECTRICAL Date
Sac , feofnlip'-. Venmfuce�f "Luk—� 1)A I�iaae Re-roofs
I '1ARDODS MA[ERIALS D19CLUSURL•
Will
nl,canprcram(mumbmldlagoaenpaaasmrearnanmenaaamaurmmarial Type of Roof
as delincd by the Carr inn Municipal Code.Chap,ar 9.12,and the Health and Safety
Code.Section 25532(u)'I
u — s
0YeF ON. All roofs Sha ns e QQr � �}'r I material being installed. -
N'illtheupplienmorfammbuldingoceupamuseeympmcntorde,ceswhich If❑ roof is in. �d'wit o it oltzll � ection, I agree to remove
emit hazmdaus air comaminams on delincd by the Bay Arca Air Quslhy Munagemem
)Wric,p - all new matenWorin cular Mpfee ids and will comply with
OYca 0 N all non-point58l&ereg&11thI i. GRADE
1 have read the hammoes materials requirements under Chapter 6.95 of the 510 — FINAL PLANNING
Califomia Health&Safety Cade.Sections 25505.25533 and 25534.1 underttand than
if the building does no,currently have a tenant.that is is my responsibility to notify the
occupant o 514 — FINAL PUBLIC WORKS
f the requirements xhteh must be met prior to issuance of a Cenifica¢of
feapan`' Signature of Applicant Date
-n,au, ,ad assn,— - -— Date All roof coverings fo be Class "H"or better