01040030/ CITY OF CUPERTINO
Irl......Nc otvtstON PERMIT CONTRACTOR INFORMATION:
BUILDING AUDRHSS: PERMIT NO,
21711 MEYERHOLZ CT TIMELINE CONTRUCT ON 01040030
OWNIdR'S NAME: APPLICATION SUIT OATH
EDWARDS RAFFIA AND MICHELLE A 1.4589 S BASCOM AVE04/09/2001
PHONE, SANI'I'ANY NO. CON'IROI,NO.
b IS ' �1 —gy Z (408)356-1790
CC'+ ZARCHIFECUENGINEER: BUILDING ITRNU I'INFO
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k 0— IILOG CLEC, PLUAIii MECII
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ucurvsco CONTRACTOR oI[cl,nun'IroN Job Description
IZO Zw t—Cw erehy nIBrn.for I an licen,ad under prnv ,ofChap Ix 9lmmmcncin
so ill,Seen n7arool Disco on3ofM1C lfn,inn,ad Potlkssiunn Codc.nnAmy
license
6 Y F J i,in full fame of 41.
at W st I.ieef, 1 s_ ua.a 5^985(p 7 KITCHEN REMODEL
°>✓o ce u owe Commelm T�wL�I-L
Id ,I,G — ARCHITI'Cr'S UCCLALN ION
di
nd.ffy plan, han lin k paimm F'A■
,V A LE D
d OWNER-BUILDER D[CLARAI'ION 2001 I hereby Minn Thal I am esnnpl font he Cunlra,ca',Liamse Law tar the SEP O ZOO 1
t
F"Z>' following mann.(Section 7031.5.Bwino,and processions Code:Any city or ,,only _
o"p which requires,a permit m ennaran,alar,improve,demoli,h,n,arcane any structure
i3m prior le its i.ssn:mce.also requires the applicant for such proaritm file o signed xtulemmnl
m:n he is licensed pntsuant In the pnwisivc,A the Conna,un's ldcense law(Clmpmr 9 Sq. Ft. Floor Area alUat100
Icco ncencing wins Sec+ion 900p of owisiun 3 of the Bu,itrcs.and P,dc„inn,Csde) B UI LDINGY
or chat he 1,exempt marerro It sad the nasi,hit the alleged tWo plien,An,violation
of Section 7131.5 by any applicant for It onon xt,bicax lite applicnm In m ,,it pcnnlly
Of m111 In..dam ave hundred dohs,650U). APN Number Occupancy Type
❑I,a,owner orf the prn.sent.car III.eml,III,ces with Is c,s,;to f Met,snlc confpec,itinn, 3264 Slb—�F, 00
will do the work,dud the structure is not intended or offered for sale(Sec.7044.
[Insioness and Pmfc,sion,Coli Me Comrecmr:License Law aces not apply to an Required Inspections
owner of propcny Who hu'udx o,imdews
prov%mecon.and who such come him,,eh
Is imugh ld,awn employees.provided that such unproven ous are to,intended(ov 1.01 — FOUNDATION
offered for safe.If,reserve,the building ar iarprovancnt is sold within one year of
,....cl o,the¢cone-hiilder will hive he waren of proving mat he did nor hand or 1.02 — PIERS
ponruv, fin purpose of sale.).
It1fJ I.a owner of the proInn ,am caclusid contracting»im licensed cnmraeors to
103 — UFER
nmi
. ct m,proles(see.7044.[1 d Pram, ,Codcora
'rhe Conlear, 1.04 — REBAR
1� e nm ieve, law dos an apply an owner oan
f property who build,or intpmves thereon.
and who contract,for such pn,}ect,with a eolmemds) Rectned pur.urat ro the 105 — ANCHOR BOLTS
Co:tracter's License Law.
01ame�lode,ov, 37,9'70(0038 .B&Pcln, hisl.,an 106 — SEWER R WATER
owner 202 — UNDERFLOOR PLUMBING
wouKER's eonB'ENsnrluN orci,AlenION 203 — UNDERFLOOR MECHANICAL
Ihereby auirnlundepenahrnflwr;uryone afthe following declarations: 204 — UNDERFLOOR FRAME
❑ 1 have and will Inainailt a Certificate of Consent in selGinsum for Worker's 205 — UNDERFLOOR INSULATION
Compensation, a, paraded for by Scotian 370() of the Lather Cade, for the
perloruccace cot the work for which dfis proton is issued 301' — ROUGH PLUMBING
O l have and will coupon Workers Compensation Insurance,as requited by section 302 — TUB & OR SHOWER
3700 of the Labor Coda fur the perllamance of the work car whelf this permit is _
issued.MyW,rkcr'sConfrn,r tion Inwrwa-curie,and Pom
Policy comber care: 303 — ROUGH MECHANICAL
canier;$'r�LL .w wli,y cors: o•Ll.—e\I 304 — ROUGH ELECTRICAL.
CERT IIhCAI'ION OI'EXEMI'I ION FROM WORKERS'
COMPENSATION INSURANCE 305 — FRAME
('Illi,eset lult need ora be enn...lo,ed it he IN it is lb,on,I,andred doll... 306 — HOLDOWNS
a Ian nr fuss.)
Icertify Jr the l"fonna— It In,cook to,,whish this permit i.issued,I 307 — INSULATION
.,hall nn etn"I.Y any Innmt m any manner,I ,uh,vo In he wmkers' 30B — SHEE"f ROCK
Cor a'.tiun L' California.Um
Appncmtt — �iq�+.os— Xe 309 — EXTERIOR LATH
NvrICE'nl APPLICANT:H.inner making Ili,Ccnihcwe,l'E,anptlon.you should
hecume s.b,,cla,,the Woke,',Comlnnsmianpan,isions of the LaMu Code....must 310 — INTERIOR LATH
O7. fnnhwilh comply all such provisions or to is permit,hull be deemed or,o ked.
Z 31.1 — SCRATCH COAT
F'
CONS ere I, onec LENDING loading
AGENCY —
a > I hereby unimt Ina here in a,,nod(So,. I0U.C agency for me performance 313 ROOF NAIL
nitidecook r,Na�„rwhiehnti,penmli,ia,a,dls,,.3a,7.ciu.c.) 501 — FINAL ELECTRICAL ENERGY
0
7 lender',AJdrec, 502 — FINAL PLUMBING ENERGY
vO agree toCordereadlll,iityandolfnnd,mlematm,abn,relawsnor ,rrdnn't, 503 — FINAL MECHANICAL ENERGY
ii [.. amara.1 agar oft I have With all city and county oNo,chat'and,mm laws relating
O U labuilding a art a by' mm rep hive,ofn:cityt ter upon 504 — FINAI, LDING ENERGY
men liI pr p sy :1 cti. p qn
t}„ Os (\\ 1 bre1 sit I tun f)and keep h nl,the City f C pen no....n9
n liabilities.Popover,0( t d pe.e, Inch y in any y against ,aid
505 — FIN CTRICAL
V % City In cnnclep enec In the u[Ineing of this pemfd.
I. 'APPLICANT DERSTANOSANDW'ILL O YW1TH LL NON- )I T Issued by: 50E1a'�7, T ate
Signature of AN,canAV, DOm Pate Re-root's 508 — FINAL MECHANICAL
IALARUOUS MATERIALS holding
(wope UISCLOSULG
witthe yteppdrnlmnnamu,al n&.Chapt aamm hwmir hu„amnw, Safeco Type of Roof 509 — FINAL GRADE
a..Jd'meJ by the Qlpcnlnn Municlpnl C'ndc,Chapter 1).12.and tire Health and Suliny
Code.Section 2255321u1! / 1
❑ve, llfi 510 FINAL PLANNING.
All roofs shall be App�cted (igrt,9.,y�n ,{ }�p61ng� installed.
Will the applicant or future building noculrunl use cyuipnfem„devise,which If a roof is installed fli outPSrsh'cY6lhini�i 9n`ids'Iiec gree to remove
emit hvandou...r connotations as defined by the stay Arae Air Quality Managemem
Diaries all new materials for inspection. Applicant understands and will comply with
❑Ye, all non-point source regulations.
I have road the hueurdous nmtcrinls naluirentcnts under Chapter 6.1)5 of the
California Health&Su(ctr Coda too 1,2558.5,25533 and 25534.1 understood that .
if the building dans not currently base a Infant.that it i,my resrytnnihililY u,nmiry the
xaapam nr n pmemeni,which Irma be tun Prior l ' uor, it uuCCenihcme m
imeapana:Cz a [LGi . YA/V!
//�� _t Signatureof'Applicant Date
wuc,araaithmnmdagent Dane All roof coverings to be Class "Br'or better
OFFICE