02020040 CITY ofcDPv SON°IPERMIT CONTRACTOR INORMATION:
• BUILDING ADDRESS: PERMIT NO. -
OWNER'S NAME: APPLICATION SUB DATE
CUPERTINO CITY OF 180 LEWIS RD 02/11/2002
PHONE: , SANITARY NO. CONTROL NO.
(408) 227-0237
ARCHITECT,ENGINEER: BUILDING PERMIT INFO
m O BLDG ELECT PLUMB MECH
•c z t - I I_7 O L-1 u
't010ENSED CONfR vCTOk'S DECLARATION
��� ...::1'nge6 Irrmma�lamrcen.edander renapmtst�a�,menring Job Description
,sal-t�i with fall berate
ad affect
on3 ofthe Businfss and Protc., Code,and my license t
a m p . is m tan Twee ana erceet.s, 33 BATH REMODEL.
C O te u License Class
Lia.p
Date S DEC2ar
ARCHII'[CT'
use UECLA A
� }�t 1 urmcrsmnd my plans shall be used as public rerords
o O Licensed Po.fe,,innal
OWNER-BUILDER DECLARATION.
n f Mreby'uNrm that 1 mo Fxempt from the Carroll or's License Lain for the
C following reason (Section 7031.5 Business d Professional Cod Any city or county
Sa O ahichrequires permit tconstruct.Mica i p demolish, p any.t murc - 5000
au 3 poo rot _Iw ce,rinc,the ii,ficamfor such pc tmfile. 'gam incernam
tlt_t ha 91 setlp _a no dr pn s ftheC t a L La ICh pa
(cam n ng Nsect ]0n0)ofDivsi 3ofthe BusmcsfpaidProfessions Code9) d,d1'`,_' ,S . F[. FloorQreax;-,.rq-fj(3a� , Valuation
or that be to esanipt mereo-'mn'and she bans for the andsed exesnrlibd.Any vmmaon
of Section]031.5 by any applicant for a permit subjeem the applicanuo a civil pcnalty
rnm -
omommanrvehundreddolmrs(s500). \APN Number Occupancy Type
❑1,an sawn<r of the propcny.sero my employee wlih wages as Meir sale crn,pensaioq 101 - FOUNDATION
-suss as me work:and the structure,is not intended or offered for sate(s«.-]tw; -- --- "- -PTErZ Required Inspections''.Business and Professions Cod,:The Collimator's License Law docs not apply to an
owner of property Who builds or improves thereon,and who ones such work himxdf 10 3 - UFER
of Nrvugh his own employees.provided Nat such improvements are not intended or - -L _-
-.oRena Tar nIC v However.Ne Wilding p t sale w,Nin one vea�a -- -b0 4-.._ ..REBAR-. _...... - - -.----...-- -
completion,the
urposerbufle.), lhave NchuMcnorproCngNathcdCnot Euldor 105 - ANCHOR BOLTS
imrrrve for purpose of sine.). .
_.____.......... . . .. ....... ..._._. .. . ,a.- --. .--.- - ... . _ ....106.. .-_.SEWER..& .WATER.___._._ -
O L os ownerpr Ne properly,am Business
iss and mraning wi Codc:)The Contractor's ncmrs m - --- --
,
= sierra me prnjat(s«.]oat•Business and erty whiobs cane:)The vesh 2 02 - UNDERFLOOR PLUMBING
r: andLicensewho Law d«s..foapply m an owner aro a conn who balms at improves mens, 2 0 3 - UNDERFLOOR MECHANICAL
.and hcontracts for uch p of n h tract (s)lice ssul punuam m Nc
cant t r L nsvu n UNDERFLOOR FRAME
0 p d s :B'&Pcfar msn204 -p�n 205 - UNDERFLOOR INSULATION
r,s
Owincr WORKER'SCOMPENSATIONDECLARATION 301 - ROUGH PLUMBING
I heony affirm under penalty or perjury one of the following declarations: 302 - TUB & OR SHOWER ,.
❑ l have aad wiii'mainmin a CamiOcaie of Consent'io alYinsure for Walked 303 - ROUGH MECHANICAL
Compepsnion, as,provided for by Section 3]00 of the Labor Code, for the 304 - ROUGH ELECTRICAL
p<rforpmore'of he work for whirh this permit is issued. 305 - FRAME
❑I have ana will maintain worker's Compensation Ireunnce,as regdind by section 3 0 6 - HOEDOWNS
3700 of the Labor Code•for the perfgimance of the work'fr
owhich this Permit is
iswa.Mywok sc.mpe -t hourbinceF eadPlicynamxrare
__ „ 307 .-. INSULATION.
_
�• ISap I:,_,'.'d`. •.•
Policy -TION 017 EXEMPTION MOM WORKERS t' ._._SHEBTROCK' k ,...................._.__. is
'aic!e 30
s, FCOMPENSATION INSURANCE' -o•. EXTERIOR—LATH
P:ld.:Ijnis sictionmird'atbe completed if the permit isfor one hundred dollars 310 • - INTERIOR LATH •0 'P''I -
S100) less.) . .. . . 311 . - -SCRATCH .COAT. -
' I en fy that n Nc perf ce of me work for which M perrrpt s issuM,l 313 - ROOF NAIL,',- .. `�t�. �- . =p...•�--
'shall t ply y pc by manner'o as to become subject m the Workers '
Cnmpe salon Lw,of C,frrva Dam - - 501 FINAL ELECTRICAL ENERGY
- A'dicam _ ._ .__... ...___.___ ._.._._
NOTICE TO APPLICANT:If, fit,making this Certificate of Eaempdon:you should 502 - FINAL-PLUMBING ENERGY -'
z baccimesubjectIlitheWinger'scompenaanampro:isionsoftheLaborCodeyoumust 503 - FINAL MECHANICAL ENERGY
Q Q forthwith comply with such rewisiens m this t shall be deemed revoked.
P pmt 504 FINAL- BUILDING--ENERGY -' --
_ . -- - " G
:� I - I`'• `°''QONSTRUCTION LENDING'AGENCY'
-
9 Rework
hichNanhertivaconmm�ionlentlingagcnryformeper4irmunce 505 - FINAL ELECTRICAL
o-•, ori „ permit is issued(Sec.309],Civ.C.1
� bwork'frr which this
p Leas sum. 506 - GAS TEST -- -
P Z
Le ader'sAddrasit - .. 507 - FINAL PLUMBING:i ;
UC
,,, 1I nfyNmIlin adthisapplcai
tom
onJstmeihenhevMvcinfurmmion tx 508 - FINAL MECHANICAL
. W cl.., art Fit I agree m comply wiN all city anB coum c�ordinanccs vnd su¢Iowa relating
QiU to , a
no arirereprscnntivesofthiscitytoenterupon 509 - FINAL GRADE
the ahuve-memionedprnpeny for inspection purposes.
F.y lWa)agreeids.Je:iimclarify and keep hamdese.theCity ofCupertino against 510 - FINAL PLANNING
r-rA livbilitics,jil ell can and expenses which may in any way acme agars said 514 - NA WORKS
V.� City in cruise seance of the granting of this permit. -
AFPI' ERSTftVDSA WILL COMPLY WITH-ALL'NON;POIN Issued - Date
Y
? I,� "; HATARDOUS MATERIAL 't S Data" Re-LOOT$
Slinnotfic of Appl _ VC ntra t t
(� - S DISCLOSURE
_� W-11 Nc Tent aro furore bu'Id occupant n -handle harudnu. emriel Type of Roof
dFfrel byYesm Conciliar,Municipal Cod Chapter 912 and Health and Yp 1 -
Cod lor"o 2553$1 t QNa t„. . •' -f .', I. �'` 'ii' '0 IF" ;iy'rrys ` ••�t t, .
All,roofs stiall_be inspected.prior to any-roofing material being installed.-
sun deapp! . t f t w lapg p t q o to devices which - If a roof is installed'without first obtaining an inspection; I agree'to remove
mitM1 b m t definedry th ByA A Quality Management
'
• Distet all new materials for inspection. Applicant understands and will comply with
4 °Y r s 0 N all non-point source regulaiions.
1 have read the Imrnrd mmmriah oi,rinam,aci under Chaper 695'bf the '
California Health&Safety Code.seri°ns 255o5:25533 and 25534.1 undersand that
if ilii building does not currenOY havea¢nant.Nat it is my rtsponsibilitywnmify Nc
occupant of
nquircments which must be met prior m issuance ofg Cenificambf
°i i Signature of Applicant Date
- e
.stn ra mmoredage t Dme, All roof covenngs to be Class "B" or bailer .
s