00060105 ct BU off cuvH
BUILDING DIVISION
st°` PERMIT CONTRACTOR INFORMATION:
H UILDING ADDRESS: PERMIT NO.
OWNER'S!;= lyltAN RD APPLICAT MM09105
PHONE: \— SANITAR 1. c .No,
0 6 Z ANCHITEC'17HP OINGER: I1111LUING ITRM1II'IINFO
w O O Ii1.UG Ii1.ECT PLUMB MECH
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Oyj LICENSED CONTRACTOR'S DECLARATION Job Description
_ 1 hereby atrim,that 1 am licensed under provisions of Chapter 9(commencing
F•w with Section 7f00)of Division rot the litioure sand P..tcx,ions Ca1,,mdn,yliucnsc
ax mricCall la nil a` (uf Li a-32937 Z
uax> PATIO ENCLOSURE
o a u Date �� ct,mmen,r_�y�
a G - /�—ARCnIrliCI'S DLCLARAIT6N
on understand l y plans shall be l public rd ^,
s� .g ('Y
LwarwdP I . I
�e OWNER BUILDER DECLARATION
CLARATION
a.�o� Ihereby'll Ilrrl exempt
atl the Contractor's License Law Irmo .
S L S rolls y N,,ol 7031.5.Brotc,,tund Prulcoit ( d A Y eiyo, ounly
F C which acquires a porn a:,snmwu,alter,imp"orJunnlieh,or rcpnir anY svuuwro
W
3� prior to its issuance.also require%rhe applicantI,"such l ocainn file a signed somaient
rhe,lef.H,en.wdpma.am mate pro.....),is it the contractor.Lank low lchapmr 9 Sq. Ft. Floor Area Valuation
t mmunc„cing with Section 700[y)of Division 3 of rhe Hein,.and Pmfe..ior,Code)
or that he is exempt thcrefrnm and the hart,Tor rhe alleged exemption.Any violation
' of Sortie.9031.5 by any applicant Ino a perms amjeco,he applicant m a coil p andly
f no,more man five hundred doHms($5(k). APN Number Oc pc
❑I,as owner of the pmpeny,or try cmploycc,will w.gcx n,me'u xolc unnpen,:niun,
µi11 do he well;,nail the arrcwm i,mot intended or.Btred rat rule(Sec.8114. 35608023. ORe uired Inspections
Business and i'rom%ouris Code: Due Contractor's License Law Joe nut apply to an q p
owner of property Who builds or impmve,thereon,and,%ho does such work himself
othrough his awn employees.pn,vided that such impr went nu am not intended or
offered for sale.1f,however.the wilding or improvement i,slid within one year of 101 — FOUNDATION
completion,the uw.cr-builder will have the burden of proving that he did not wild Lir
impmu,r.rporpoxe orxalc.). 1.02 — PIERS
❑1,as owner el he prop,.,y.am cxriu,kcly concerning wiill he...call comm,t It, 103 — LIFER
r tl,nmme,the Fiber,(Sec.7014.Nasion,,and Prom,,in a,Cale:)The Cumramo,'a
License Law ares mor apply in an ounce of pmpenr who build,or impmve.thereon. 1.04 — RE BA R
and who contracts for such projects with a c.mmamf.)licensed pursuant to the
Contractor,Urenxe1., 105 — ANCHOR BOLTS
❑I mm exempt under Ser. .It PC Tor mi.,rectum 106 — SEWER & WATER
`'woof WORKER'S COMI9?NSAI'ION DECLARAIION 202 — UNDERFLOOR PLUMBING
I wmby am r.a under penahyof pr,ja, maroffle following dedimlom. 203 — UNDERFLOOR MECHANICAL
0 1 have nod µill mawai..Ceeduale of Consent to Klf-itwne foe Worker 204 — UNDERFLOOR FRAME
Cmparroomn. us provided for by Section 37M of the Labor Code. for he ^e05 — UNDERFLOOR INSULATION
performance of the walk for which,ho aemil is issued.
SCrJ H ; it w ill maintain W..oa Contperiminl ln.ura"rc.ax minimd by Stair.... - 301 — ROUGH PLUMBING
/3mg1 or me Labor Code,Ter ter pr,lomn�tm,of ler watt ler wenn mix pernni,is 302 — TUB & OR SHOWER
sued.My Wop ker',C o,P;2tiun In,/nrptcc carrier nal Ink,name,,arc:
31 � e (LAJxPlmyNo:12 0 ^�� 303 — ROUGH MECHANICRL
CERTIFICAT[ON OFIecmvr[ON FROM ORKERS' 304 — ROUGH ELECTRICAL
COMPENSATION INSURANCE
I'ani, .iamneeda bereoiple,damefac,nihl,forltehand¢ddollars 305 — FRAME
oW0)nrlr,:.) 306 — HOLDOWNS
1 cenfly mat in he perrnm,nco,of me work for welch this yemrit ix issued.I 307 — INSULATION
shill not employ any action i y rw ,.bile , Workm
compeernio.I. alifo 1 e ii 1. `�ae— �`' 308 — SHEETROCK
Appli<anr � —
NOTICF.TOAIIfcFuT:i(Tr kmgLmIce�nllrmr of Exennpoo..you,need 309 — EXTERIOR LATH
n,wmc nuhN,,to the Worker.Cmnner,mion rootoun,o1'the Labor Cole,you next
O O mnnwhh........1,1a1,such Ino'sinn,or ads permit shall be deemed revoked. 31.0 — INTERIOR LATH
CONS I-RUC]ON LENDING AC12NCY 311. — SCRATCH COAT
x ' 1 heathy affirm Hort there is a consumed..)ending agency for the perfomnence
trim work foe which his perm),is i...M(See.3097.Co,C.) 313 ROOF NAIL
""dC15Name 501 — FINAL ELECTRICAL ENERGY
5 Z Leader'x Address
V 1 ,re Ihtit with
,, rod and state mod rite b t—re'on ,
correct l y' , et 11y d e11 'ty:u l ,Y f oro I ,eeh, ng
(� alb Wi,- :, 'dt JI by nhr 1 tl"x I,M1':horny eon Po,
he nbovcmemme uxi amimny fur in,a and
M purposes.
F iy
(We)ugn<e to save.inJunnify mA keep harmless flit City of Cupenin.againet '
Z) liabilities,judgment.,,costs and expenses which may in any way acme against,aid 2 — FINAL PLUMBING ENERGY
C„) Z City in consequence of the granting of this perm:,.
APPLICANT UNDER.lTAND$A d)WILLC PLY WITH ALL ' N NTssuedby: 903 — FINAL MECHANICAL V"ERGY
SOURCE REf ONS / �
slgn.mmo hairnnuammrmt — -- ate Re-root's 504 — FINAL BUILDING ENERGY
un'lofium Marr:occupaDsomeorOR° 505 — FINAL ELECTRICAL
Will meapplicantor fuwm building occupant some tie .([the M1vnMoan Safety Type of Roof
Code.Section
the Cupertino Municipal Code Chapter 9.12.an([the Health and Safety 506 — GAS TEST -
G,de.OYa 25512(v)? E3 No
All roofs shaf607inspeffeliytA'ly'tPtu1JM1@U:rWmaterial being installed.
Will meappr,.nr or mmre handing Ocrulaa"l are claiwmcm ordevia,which If a roof is in5ogd-wit WRI+I okLajnjqppjjiMVction, I agree to remove
omit hamnlou,air conmnocanL,Lir delhmd by the stay Area Air Quality Manugancnt
District? all new'mate§4doLjnlpgc](1 ? Mj� understands and will comply with
❑Ye, [3 No all non-pointce reo i �.
1 have read the hmmdo.,mammal,mquiremen,x mala c,Ch.p, 6.95.1 rhe 8`11 — r Nf�L PLANNING
California health&Safety Code.Sections 25505.25533 and 25534.1 understand mat 514 — FINAL PUBLIC WORKS
it the building does nor currently have a,enont.that it is my rnln,roi idity m notify the
.Oratim Lit Ih,requirements which nm.a be me,prior or oounm,u Ceni'e:ace ill
oanpanry' Signature of Applicant .. - Dale
owra .r aummired agent 6 Ga,�� All roof coverings to be Class `B" or better
OFFICE