00010091 CITY OF CUPERTINO PER'MU`NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMA,T'ION- 0 q 1
0 / Q 10 4
BUILDING ADDRESS:
22141 LINDY LA SANIIARYNOAZI1IAqMleKjV)"UBMU`TALDAT
OWNIiR'S NAME
AND MARIA I NIG 01.�1'9viEtQPQ
.� PHON::: ❑
ARCHITEC(ENGINEER IiULDING PERMIT INFO
❑�'IpI..
yQ A
>-o s= 1 hereby,ffi.Nat 1 emED Clicelu�A R pori ons of[Iuplu 9(wmmencing Job De ' JM M�r
F=Con wish Section 7000)ofDivision3oftm Bu.ines.WPofe..was Code.am my license is
<xs� imm�fsceameffect. ADDITION 16. rtDot
Lions,Clan Lt.# JUT.
Dem Contractor
h n.O ARCHITECT'S DECLARATION /�
f g IunduauMmyFlats slullwusedupublic bereeds
aBUILDING
of
do a Licwed Profcaioul
n v OWNER-BUILDER DECLARATION
1 hereby affirm Chat I am asner,from the Contraurs License Law for the
r D following reason.(Section 7031.5.Business and Fireflies..,Code:Any City cr county
wMeh acquires•pemnit m aomtwct,alter,impoK.demefim.err mlav erns mucmue S Ft. Floor Area Valuation
prim to its issuance,also requires de,hApplicator for such permit to file,sigh,d mumem q'
that he is licensed pursuant to the previsions of the Contractors License Law(Chapter 9 $128Q100
(commencing with Section 70)0)ofDivision 3 efthe Bind.ad Prefessioru Code)o ppN Number Occupancy Type
Nat he is exempt therefrom and thr basis for the alleged exemption.Any viohu°n u
mf P Y YP
Seedem 7031.5 by any applicant for a permilsubjects the applicant to a civil parody of
not more dun five broadcast dollars(x500).
I,u°wnerof Nap ay.mmyempl° swiNwagouNirwiecompe m, equire Inspections
will do the work am she suueore jams i nromm ser oRerm formal.(Sew.7040.Business
and Indictments Code:Tha Conmenchr't Liana law does Cont apply to an owner of 101 — FOUNDATION
precise,who builds or improves thereon.W who does such weak himself or through
his own employees,provided that such improvements are not intended or offered for 102 — PIERS
sale.If,however,the building or improvement is sold within oh,yeas of rompletion,the
.. kwill have the writer of proving that he did not wild m mission for per. 103 — UFE R
1 a 1 04 — REBAR
u..o
[�L f Ne property am exclusively combating wish licensed contnemn to
commmrct the prefect(S..7040,Business am Pr°rrasiom code:)The cmawr
rtrs u- �05 — ANCHOR BOLTS
cause law does nor appy to an owner of property who bund,or impovo thereon,and
who conbactsfs such projects wish a contramr(q lcensed puamorto the Contractor's 1,0E — SEWER & WATER
ucaua erre.
❑Imme.e p o r/sj/�/��� '7�y.BkPCfor this reason � 2 — UNDERFLOOR PLUMBING
owner /.RSLtte-eaA�-"i-a-D• 3 — UNDERFLOOR MECHANICAL_
WORKER'S COMPENSATION DECI.ARATTON
herebyaffirmunderpcnallyo1peJurymneofthefollowingdeci ations 204 UNDERFLOOR FRAME
❑Ihave amwill maintain aCemificaneofcomermtosalf-inwre for woa sCrimper- 205 UNDERFLOOR INSULATION
Baron u provided for by Section 37W of the Labor Code,for the pedomaree of the
su _
work for which this permit is ised. 301 ROUGH PLUMBING
0 1 have W will Cautious,Wstars Compensation Insurance.as required by Section
3700ofthe labor Code,for the radormanccof she.,it for which this permit is insure. 302 — TUB & OR SHOWER
My Workers Compensation Insurance carrier and Policy number are:
Carole: Policy No, 303 — ROUGH MECHANICAL
CERTIFICATE OF EXEMPTION FROM WORKERS' 304 — ROUGH ELECTRICAL
COMPENSATION INSURANCE
(Thissaum recd net bewmpleutlifdre pemdt it frrone hurdNdrllars 15100) 305 — FRAME
or It..)
Toy my prison
in the my manner
shewskfor wubje this temtirsiuum.lshal 306 — HOEDOWNS
retemploysaypeasoriaeerymannerwseat°becamesurfersaOreWorker'Compo- 307 — INSULATION
ation taws of Cdifomi.Dare
Applicant 308 — SHEETROCK
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Wooers compensation pmvldmns of rhe labs Code,you must 309 — EXTERIOR LATH
fembwhh Comply with such mr,iii.s.or this permit shall be deemed rev°km.
310 — INTERIOR LATH
CONSTRUCrION LENDING AGENCY
o ZO Ihereby efforts Nerft.iissuenatm.e 7.Cing.geneyr«tneperrarm.nceor 311 — SCRATCH COAT
Zthe wort for which this permit is isms(gec.1097.Civ.C.)
F Z T<mersNae 313 — ROOF NRIL
Termer.Addrexi 501 — FINAL ELECTRICAL ENERGY
a I comfy sur I have read res aWlie°Con and sum that the above information is
a
Correct.I appose to comply with ell city and county endurances am static laws retiring in 502 — FINAL PLUMBING ENERGY
i^1. Z budding Coeerstone.and herebyacthoticc repfesenurvel of this city mance upon the
L) 0 above-mentioned nopnyfor inspection porpoises. 503 — FINAL MECHANICAL ENERGY
W = (we)rupee Save.Indemnify rum keepyoured rthecityofCupertinoagauut 504 — FINAL BUILDING ENERGY
V Iiabiliro.jmgmrnu,C.am espensea which may to say way acwe agdnst said City
y W recon, eorthegmnbngufthisparmit. 505 — FINAL ELECTRICAL
C. err APPI A TUN :RSI'ANDSANDWILLCOMPLYWITIIAI.I.NON-POINT
v z S(' ` "fi' IIO"S 506 — GAS TEST'
507 — FINAL PLUMBING
rolur.of Appfcam(Contractor I Data
HAZARDOUS MATERIALS DISCLOSURE 50B saw FTNAl MECWAN
Willtheappbcom or future wilding recopumm
tsorlandle lassmaterial aterial Re-roofs - 509 — FINAL GRADE
as defined by the Cupertino Mubciod Code,Chapter 9.12,sed the
Health and Safety Type a of Roof
Code,Section 25532(.)7 510 — FINAL PLANNING
❑Yes ❑No
Will the Vnicart or future building occupant use equipment or devices which All roofs shall be iMpeetetphlOkt(PiiW.�LiMfl ig%5terial being
emit Nwdoes aur cmnumirunaa,definm by Ne Bay Arca Ab Quafny Management installed. If a roof is Installed without first obtaining an inspection
District?
❑Yes ❑No I agree to remove all new materials for inspection. Applicant
Ila, hateaddrus materials regoi,ements Coder Chapter 695 of the C.Ti- un erstands and will comply with all non point source regula&Pns.
I..Ha A,Safety Code.Sectimu 25505.25533 and 25534.1 ma ersard that if the
buildin note have is aunt,that itis my n,"colility to notify be occupant
elitist i must 'ermiswarceofacoull11 of Oauparcy.
dIJ Signature of Applicant Date
err or aulwneed agent I Date
All roof coverings to be Class"B"or better
OFFICE