00060101 CI'Py OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING AUDRISS, IF_ "H PIiRSII'I'Ncl.
ousiNfik-siBiR400 JANICE AVAPPLICAT 1101 '
o sed cu& 1
PHONi: HSU SANT Afft A[ti /15/201240 No
❑s Z ARCIII'IHC'I'IF,NGINFFR: BUILDINGP IcNin INFO
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S z LICUsSEDCONFRACfOR'S DFCLARA'I'ION Job Description.
y I hereby alum,the I..,licensed under pm,idmm,of chapter 9(commencing
F,Nf-u with hill in cekind of Divivion Jnf,hc lfmine,�anJ l•rnfen,inn,CWe.nnJ mylicemc
m j i,in lull li,ms:mJ%flee
p u Licence Clans_g Lic.b_ (!
MDate—�- tt o.. comtr:'"°` ADDITION
3 u G ' ARCHI'IFCI"S I)FCLARATION
t st 5 J rend r Ions, II be a ed:,.public record,
of o Ideensesl Pratan,nnal
a'.?oOWNI?R-BUILIIFIt DFCLARA'I'ION .
u� bemnr arm„lo-,(I am exempt soon ore Contractor s Uccr)w I,aw for me .
t z< billowing rearm,.(Seedon 10315.Bosco,and Pmfex,i,ms Ctac:Any city or county
E x a which regr,ires a action to construct,alter,improve,demolish,or repair any suuaum ,
Four to it,issuance.also require%the applicant for such permit to file a%igacd statement
that he is licensed pursuant to the pmmaons or the Commences license law(Chapter 9 Sq. Ft. Floor Area Valuation -
(cuomoncingw,ill Section 7(XX))of Divi,ion 3 of the Hn,ine,%and Pn I—inn,Cods)
or tow he in a%cn,pn tha'cfmn,nnJ the bmf,I'ar the alleged cacmptiam,Any violdim I
,it Suction 70315 by any ap,heann for u permit s.b,c.,the appliom in u civil penalty
of nm mom thanfi%e hundred dollars(s51x), APN Number Oc@up@953spe
❑L as owner afore property.or my empmymc with wage,ax their sole counteraction,
will Jo the work,and the structure is not intended or offered for talc See.7(A4,
Ifncineu,amt Pr,mnni„ll Code. I'he Contractor's ucena l.aw doe,non apply In an 35701.051.. 00equired Inspections
r m'prn,fy will,halt,),or imp.n,e,tbe�...and won does w If work It elf
owner
his own employee,.provmed than such imprnvanentx are nal inncnded or '
offered for%ale.If.howee,the bu ithng at impardsencm is sold within one rear Of 101 — FOUNDATION
completion.the mencobuildcr will nose the harden of posting that he did not build or
prove for porlwccor,mn)' 1.02 — PIERS
III owner of pill tr arn exclosively c(noractingwid licensed condrach',t, 103 — UFER
tinot to p , ora mnof silo, f :: r„c,v,) Inec lc n 104 — REBAR
ro. c J tappyn ofp Peb m dlif- hollows,m� n.
and h e t t. fi r h p j<a: ith t t t(sl aJ p t to the O/
comma L La 105 — ANCHOR BOLTS
❑lumexcm tunJcr Scc. .H&PC h,rthnrtason /Q
owmer. titn—Date 6�L Od 106 - SEWER &' WATER j/
WORK:R's LD b4SKI[ON DFCLARATIDN 202 — UNDERFLOOR PLUMBING
(hereby affirm trader petaalty of perjury at ofine snowing delmeion%: 203 - UNDERFLOOR MECHANICAL_ O
❑ I use :,sod will "roomah, a C,dd arc of Consent ,,Bell-lo...e dirt winker, 204 — UNDERFLOOR FRAME O
Cmnpc ion. us nr%idea for by Smdmr 37x1 of me Lmor Coda liar he
pcrromlo;«ofthewaAmrwhichmi„sco,ofi,i,led. 205 — UNDERFLOOR INSULATION
01base sadwill...aniaWorker'sC...npemalumInsurance.a,rectorial bySection 301 — ROUGH PLUMBING
3700 of the Labor Code,for the pefrronn.ncc of the work for which this permit is
issued.My Workers Compensation lawrancc carrier and Policy number are - 302 — TUB & OR SHOWER
Carrier Policy No.: 303 — ROUGH MECHANICAL
CHRTIFlcnr[ON op Uxl!Mvr]ON FROM WORKERS' X04 — ROUGH ELECTRICAL
COMPENSATION INSURANCE
Ends section need not be completed if permit i,for one humbed dollar, 305 — FRAME
islaoale,,'1 - 306 — HOLDOWNS
I certify that in me 111,,rmarnv of the work lot which this peonif 1.. d.I 307 — IN
SULAT I .
shall nod empty any Per.an in any Bonner w a, ,,hecene sunjcn n , Wt. en
Campcnmtian Law cry rnmia.Date (�' /_j'' o_r 308 — SHEEFire, T
NA no
(yllCli T(I APP ICAN'I`If.nfor mxAi gthrnC BIL rte ill Exemption.You should 309 — EX E H
hvnmm nuhjc,n tomo Worker',Cnrnpi....pmvl..t ofnhc Lutxa Cods,you must
O 0 rmo,will cnolply with such provi,iom%or ods permit shall he deemed revoked. 310///__-/�I.N ERI R LATH
CONSTRUCDON LEN DING AGENCY 31 a/ / /�C TCH COAT
1 hereby affirm that them is a commoaimn lending agency for the performance .�IVN'/
anile work red wean this ,t %moven(Sec.3097,civ.c.) 31.5 ROOF NAIL
to crd ' ARd—, 501 — FINAL ELECTRICAL ENERGY
VO 1 edify that lbase read this application and nlate lh., hesMvclmfonnmianis502 — FINAL -PLUMBING ENERGY
4. F. correct.1 agree to comply with all city and county molmorees and%tate law,relating
o L-'l
O v mbuilding construction,aadhereby aumoberepresentatives onbi%city toenter upon 503 — FINAL MECHANICAL ENERGY
>„ ti7 me ahovc.owitioned pmpuny m,imlecomr purpose. 504 —
FINAL BUILDING ENERGY
a (We)E,c,1—ase,indermoil'yamdkeeploamhen,'heCityIdCnperfu,aagam'(
H to liana ice,judgmeml,,ca>1,and ispenw,which may h,any way acerae ugniod,aid 505 — FINAL ELECTRICAL
C.7 z City in crm.....rec of the granting of this pi
r SAPPLICANET OURCEREGUIDgRSATENSNDS AND WILLCOMPLYWITH ALL NON-POINT Issued by: _50�a — GAS TEST Dale
s eon non tai ticm,oaetm `-`6tile�T�:,(•�”
Re-roofs 507 — FINAL PLUMBING
p ❑A[ARDOUS MA'I'I:IUAI.S DISCLOSURiI
Wll the dpprmmnor mem building oecupart store or handle In—mi orderial Type of RooF08 — FINAL MECHANICAL
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety 509 — FINAL GRADE
Code,Station 25532(.)'
oyes ryC All roofs shAjVinspe;Rq$jMLor PlapkI ItI61naterial being installed.
Will life aprlican alattice h"udmgaeropantmceq,ryunemnrdevor, Idch If a roof isil t d_wi st2 n n n, Iagree toremove
cI,holrodou%:dr,,ano minur,a.dcrncd by me bay A,ea Air Quality,Managcmem, RJ�� 41'kJ19L�G IUIJ12f3t9
Dkido? all new materials for inspection. Applicant understands and will comply with
CI ye, t all non-point source regulations.
1 have read the I...mon,..,craft,regairemcntn under Chapter 495 of the
C.lianniu Ijealth&Surety C,N ,ticcnlmrc 25505,25533 mW 25594.11 dcntanJ that
it the building duct not%apart ly hove a menu,than It in my ec,ann,dolity m notify the _
mcupunt of the requirements which lost he met prior to Issuance of a Cendicaw of
G"" ""`r' Signature of Applicant Date
Dino "t ��- a,Ov All roof coverings to be Class `B" or better