00080017fY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BULLDItNGAI )�{ $:_q y PERMI'I'NO
�. 1 /.5 LA NAR DR l a D.ie 1 Y7008001.7
OWNER'S NAME:
1•R(.)01q
OARCHHE I/Cle(do[¢N:
ul
Z.
y i LICENSED CONrRACro i DFCLARAHON
V . �+'� I bcreby ufonn nut, I not licensed unit, ........inns of Clu.pter 1)(eoimnencing
with Section 900X)of lot,
lof.aeBucinessnnd promsion,CWe.and my licetlse
is In full force and dial.
w 2
w I,iccn.c Class Lic a
� o o Data Cm..metn.
J 3 _ r. ARCHI'r per's DECLARATION
f = C g I understand my plan., Shull he ocM n.v public mcold,
w ¢ 6 Lieumcd Pm@a,oull
OWNER -BUILDER DECLARATION
uai u I hereby d ounuffal I ant exempt tram the Cntltn.ctnr'.v ..tern., law for ,he
C L following ruoan. (Sv,6oa 9031.5, Il -o— and Pndcxsimlx C'Ixic: AnY city nr aanmy
Y C which wquiresa perunin ulcon.wom.alwu impms'e.de.no.ish,rlrrepairanystmeture
i 3 m
prior to its issuance, also requires the applicant for such Penni, In rile a signed stawtltem
that he Is heesad i umuunl ,, ihe....... ioncot thb Crnvadof, I.ifrree Law (Chops, 9
(comn unit, with Scuba. 7 00) 111Divisin 3 of the Bain ns and Pmtesions Cade)
or that he is eacmpt therefrom and the basis for the alleged mempriun. Any violation
of Seclion 7031.5 by any applicant for a.ennit subject% the applicant to a civil penalty
A no, u.m'e.h.m live hmuired dullan ($500).
,-e 1, as owner of the pmpeny, to my employers w ith wages auheir sole umn,it,. ion.
will do the work, and .he ancone is no. Intended or offered for .ale (Sec. Slot.
B.Iua ss and Ymfcncinns Ctde:'I'he Cnnn xon's Linn¢ I.aw due, not spay m all
owner of po.,i Who hailds nr moral drerenn. and who dlcc such work himself
nr through his own employers, Imoialed that such hoprm'enwms arc non intended or
oftercd fu.'.ade IL hnu r. the briding var finprovenuarn is wdd within Line you of
complct ton. We owner-huilder will have the burden of proving that he did not build or
improv, for "em of nulcJ. _
❑ 1, ns r nl'.he .roput, an ., I..ivuly nn uann, vial, 1, licen.W cunt.....hors ill
Ledam, the project (See. 906,1, Bosuns. and Pmfc... on, Cide) The Comnmmr's
icense Law does not apply to an owner of propeny who builds or inlpons,hemon.
and who eommcts for such projects wldl a contraetaral licensed prmumlt ill the
Cono kouve, Liucnce Law.
❑Ion exc p, unI 9 1111&PC for this atom..
t"IS
wner_ - 3^r Da.e �•l I-' V'
'lik'S COMI'EN$A'CION UECLARAfION
t
I hereby upon under pciakity of Perjury one of the following declaraiom:
I 1 have and will main,xin a Cernficaw of Conan, to self -insure liar Worker's
onlPensmion. as provided for by Section 37x1 of the labor Code. for the
arlor au,e ,I the work for which .his nenllit is issued.
I have and will maintain Worker's Curn,sumation Insurance, as required by Section
7X1 of the Labor CWe, for ,he perforrounce of the work for which this Permit is
sued. My Wrrker's Coailwar:uion loserano carrier.tnd Ynliey number are.
urrier: Policy No.:
CCRPIFICACION (111 EXEMPr10N FROM WORKERS'
CONII117NSA1'ION INSURANCE
ohis section need nut be completed if the permit is for one hundred dollar,
I not or len,..
I certify that in the Perfonnunee of the work for which this pennil is issued. I
,hall not emptily any lmmnt in any manner so as u111ecanne subject to the Workout
Cn.npen.uion I.uw, at'CAifnr..i a Doc
Appbcon
NOTICE TO APPLICANT. IL after making this Ceeiftcate of Exemption. you should
tress csubjem todo, Workef'sCanl,knsalion provision ofrhe IaMn Cade. You nmst
Q 0 fonnoun eontply whh such nro,kion, nr nil, per. Lit .hall be deemed revoked.
14 CONSTRUCTION LENDING AGENCI'
1 herehy allinn ,hat ,hem is x co olruelian Icnding ngeney for do, Naforru nue
fr] of the work for which Illi, permit is ksued (Sec. 3(M)7. Co. C.)
0. Lendei. Nwlrc
z Lenders Address
U Ql cenily that L have mad this application and slate that the an'
tne information is
li t... correct. I agree to comply with all city and county ordinances and .fate laws relating
build lug pat.. mc.Ion. and heeby ar have reptewnlmives oflhi, city it enter upon
1y 1x7 O c all uvo-.Li nlioned pmrymy for jncpaliun pnrplan.
ry (W',) agate m save, inde.nnify and keep h.oles.c he City of Crpcnim agaiod
t4 Will In ies, judgments, eoas and expemes which fully in any way acerae against said
U T City in conmgncnce ill the grarong ol'this panni..
s SOURCE EGULATIONSNDS DwILr.r�OMYLY WITH Q's -L,
HAZARDOUS MATERIALS DISCLOSURE
Wil be applic int or follow Ivilding n=.pant store or handle haourlu us natenal
as defined by the Cuponinr Mouncipal Calc, Chapter 9.12, and the health mW Safety
Code, Sn,im125532(.0
❑Yes ftx�`
Will the applicant or fulum budding oea.paml ucc Is, proen or devices whirl.
enlit Ilvmdoux air c ntannunants us defined by the Ray Arca Air pnati,y Manugen c n,
1 iarim9
❑ Yes
I have read the hvaNnus mamnal.c requirements under Chapter 6.95 of the
Cuhhsmiu Health & Safety Code. Sections 25505, 25533 and 25531 1 understand that
if the building dols, not emrent ly leave n ¢runt that it is illy resp.mcihi lily to anti I the
,upon, III list w_gri/mnatlygl1n which must he wet I, .swan, of u Ceni lunee of
(kcuptnry.l\1�AS.li1lV-
RDS
IILDG ELECT 11L.UMR MECH
I_.-1 I.-1 —1 I - I
Job Description
CHANGE_ EXI:STa. WINDOW TO
Bi:X:f.ST'3:IdG IJII>IDC1W:3
/ ei
^ REt{uired Inspections
PATIO DOOR AND
1.011. - FOUrIDnT:F.OnI
1.073 P1ERS
:1.03 - UFER
1.04 RE'I3AR
:1.015 ANCHOR DOLTS
1.06 - SEWER & WATER
P.011.3 •- UbIDERFLOOR RLUMI3I1AG
203 - 1-I11DERFLOOR ME:CHANICAI_.
is?[3{i UNDERI-T_OOR FF't(1rIE:
205 - UNDERFLOOR IhISI.JI._AT.1014
3011. ROUG.1.1 1,11_UlIBING
302 TUB & OR SHOWER
:304:3 ROUGH MECHAIdICA1_
304 - ROUGH,E•LECTRICAL.
305 - F'RAVIE
306 1-10L.DOWNS
307 INSULATION
308 - SNF:F::7ROCK
3019 - EXTERIOR Ln'TH
31.0 '- .1:NTER:COR I-nT'I'I
31.1. - SCRATCH COAT
.:3:1.:3 - ROOF' blAIL
5011. - FINAL ELECTRICAL ENERGY
6(.(.3 F':I:hlnl- PLUMD1.1,1f33 C7NEi:R(3)Y
.`503 FIIkAI_ ME.CHAIA1Cnl_ ENER
5014 - F:Cbinl._ BU11-DING) EhIIc:RGY�
505 - FI:NAL ELECTRICAL
Issued by: _gT)06 -' Gni:)'I'FHST Date
Re -roofs :tai -- r a.rvl-n_ FL -1- -UL11rvL) .
Type of Roof
"`1g)08 FIMAl._ IIE:(::Flnbl:l:f;fol... `•
,L7 .a •- F:I:Nf-1L GRADE
All roofs shall$d being installed.
11'a roof is inst5l1e6 withJuN fiIN.Dbfi(dI16 ICinAQ {fl4Si I agree to remove
all new materials for inspection. Applicant understands and will comply with
all non -point source regulations.
Signature of Applicant Date
- All roof coverings to be Class 41131' or better
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