00110121 CITY OF CUPERTINO -
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: /
BUILDING ADDRESS: PERMIT JO.
10191 HILLCREST RD GOLUB SHERMAN L AND VIVIAN T0110121
OWNER'S NAME: APPLI TION UB DATE
GOLUB SHERMAN L AND VIVIAN M 11 222000
PHONE: SANITARY NO. CONTROL NO.
O O ARCHITEC(ENGINEER: BUILDING PERMIT INTO
Z❑❑ BLDG ELECT PLUMB MECH
6 1-1 I— CJ
t° LICENSED CONTRACTOR'S DECLARATION
le z 1 hereby ffirm that I am licensed under Job Description .
QZ ya provisionsof..Code.l(commencing ADDITION OF 790 SQ. FT.
F=t with Scallion 7")of Division 3of me Business anJ Pmfessians Cale,and my license
ae y m 5 is in full force mQ$kc
c
W,-< Licenu CI /L/'/ Lic,o Ly v
a' U 41
Dal Cmntmctor C
'U.0{-n ARCHITE 'S DECLAR St r hC 0 '��, ��
undem lam shall used as public records I 6
vr1>
w a O sed Professi I
e'F m LL OWNERLIT DER DECLARATION MAY 0 12002
1. 1 hereby affirm that I am exempt from the Cmnm<mr's License Law(ser the I $76321
t Z a following re n.(Section 7031.5.Business and Professions Code:Any airy or county
0
E A❑ which requires a permit to construct,eller,improve,demolish,or repair any structure
paj3� -primidits issuance,also requires the applicant for such permit to title a signed statement - -_
thell.Aliaeoxd,mmen othepmvisionsofdoContmctor'.eLicemetawfCWpter9f30rpfpea;;,,; Valuation
(commencing with Section 7000)of Division 3 of d,<Business and Professions CaCode) s, 'Mr.
pl s
or that he is caenipt therefrom and the basis for the alleged eaemptlon.Any violation ,
-of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars 19500) 101APPPN PtWftATI ON 1 Occupancy Type
111,as owner of the property.or my employees with wages as their sole compensation, 102 - PIERS
--will do the work,and the someone is not intended or'offemd forsale(see.lour 103 - UFER
Business acid Professions Code:The Con
ntmom r's Care.Law does napply so en Required Inspections-"' -
owner of property Who holds or improves thereon,and who does such work himself 104 - REBAR
o er through h' employers.provided had such improve to t intended or _
.opal-a fo n 1 .If,se - nth have
the improvement n m f ui r of .. .. 105 ANCHOR BOLTS
'c plve the n n mrwuha�e�neomaenafprav;nLm:nneaanotnauda, 106 - SEWER & WATER
improve for pumose of sale).
❑asur der afih<pmperty:am BusinessaaPatesi... Rc<nsce Conaciarsm - ERFLOOR'-PLUMBING "-' -
Lic nee roe does
(sic. 1.a,owner s amc ern who ba Cods:)The ewtmcmra 2 0 3 - UNDERFLOOR MECHANICAL
License Low does not enc m an owner of property who bulice ser improves thereon,
,: . and.who,.nLiwinn frsuch projects whharommmarta7..hansea.pursuant.(,.the. ...._.......-...204- "-UNDERFLOOR-'FRAME_.. ... --.. .. . . . ... ...
' Contmcmr s L cense Low. "-
t. ❑I.mesemptunder 5ec. ,B&PC far this reason 205 - UNDERFLOOR' 'INSULATION
= Owner '- Date 301 - ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION 302 - TUB & OR SHOWER
-1 nemhyafran tinder lKmhr,of Perjury ohm gl'me.e,llmwing declarations: 303 - ROUGH MECHANICAL
tdI/blase, did
will maintain a Certificate,of Consent to self-ina,me for Worker's 3 04 - ROUGH ELECTRICAL
ie ti 4 Compensation, as provided for by Section 37M of the Labor Code, for the
perfam,ance of me wodk for which this pe.I,is ts.aed3 05 - FRAME
711 h d will dnt Wo ker's Cc.an,amortion Insurance.as required by Section 3 06 - HOLDOWNS
37011 of the Cub dr'Code for the perform c f the work for which this prim t s 307 - INSULATION
issued M Wo kers Curatorial,t n I suturae certier and Policy bel re:
308- - SHEETROCK
"Care ' `Fall<yNm'o0B783v
ERTIFICA OF E N FROM WORK€RS, 3 ." 30 9'ti-: EXTERI ORS. LATH 1'
' COMPENSATION INSURANCE, ___-_„_
310. ,-INTERIOR--LATH
This iemod riled not be completed if he permit s future hundred dollar. 311 - SCRATCH COAT
(sHxn s.l t
I tf .fhaii the r(o �< nits krrvi htn - "'-313 - ROOF--NAIL—
"I
OOF--NAIL-
Y. pe pe t is i ueda
'4half
m employ stay pe ,n any manner so as m bee a subfen to the wogen 5 01 - FINAL ELECTRI CAIS• ENERGY '
"aPpe01yam l.ow"'I"d odain Date .502 ._-. FINAL..PLUMBING ENERGY. ... .
-NOfICI TO APPLICANT If erre k .gth Certf , til crept un you hat la 503 - FINAL MECHANICAL"ENERGY '
Nee , h)con th W A 'Cnmpens......
i p sons of th L ho Code,y umuu
O Rmnncreplywith hpwl"allortu're usIndredeeneJ voted _ 1. _504 _- FINAL BUILDING_ENERGY
z`y "•o, CONSTRUCTION LENDING AGENCY 505 - FINAL ELECTRICAL
i-
� >'� 1 thereby aRna tat here is a con.au tion lending ager y for the lir,fam un<
orbs oararwn<ntn pemtisissaeuls 3097CivC1 506 - GAS TEST
yA -I d Name ....._. ._._ _. . -_ ... -. . .. .. ..._. .
pyz Conder nlaress -. - 507- FINAL `PLUMBING.,. -' -
_ U'O y ands,a,<mattheloosemrumatonis 508 - FINAL MECHANICAL
I cent that I have read this application
s F m rest:1 agree to comply with all city and county oNirances anJ s ¢laxp rclatin8 509 - FINAL GRADE
1.'OV .11lamngcnrm rat
p enmiv (m.say 1. nterupon 510 - FINAL PLANNING
y fy 'the ab e,c tic p p ry f r fp ct am rpm s
1W b e J Iy dk ph 1, C,yad6apen ' ,_aoa
lib id dyi ,t t 1 y' ,aywy ,<agm nsaJ 514 FINAL PUBLIC WORKS
N,1,.� C ty n s ace 1 1 thing of th , rat ^/
APPLKA NDERR AND WILLC YWITH ALL NON-POTNT
s L uL:nD Issued by: Date /
Sig)"
tt• A,Pita ,u oar.: . " .,. a}e .�' Re-roofs
- RDOt15 SIATERIALS DISCLOSURC
i W ll the uppl' t 'I t h,i lA g u ape t i o h JI za u� ,x t I _ -Type of ROOF - -
as dcfineJ by the C pen AI c pal C e Chapter 9.12. d the Health and Safety
Cale 1 1
I ... i ,
_All roofs shall be inspected. nor to any roofing. installed., .
P _.
W II the app,' t f t b lam < p t eyu pn t o device,which If a roof Is 1I33t911ed without firs[obtaminre 8n ins eCtlpn', Ilagfee:to remove
mail ha 1 o t a. c of by th Bay Are.Ai Quality Manny marl .. o P
D t l? o all new materials for,inspection.,Applleant understands and will comply with
all non-point source regulations',, ,
1 huyc.r�•ad the haza,Mu: amnalx rtgt' memsunder Chapter 6.95 of the
Calvo �Fle th&Safety C ' cation/yb 25533 and 25534.1 understand that
.. .. .. .. - t .. . .-._. ... ..
oes not cn tl'huve att it is my responsibilitymnnli(y the.
' tic ginm Yf is rcquve I hlch musprint,1.Isstun®eof n enifrote of '
-. On - sn
Signature of Applicant .._ Date
/ monis t to All roof coverings to be Class"B"or'better
s
OFFICE ....