00090063[11117[93
CITY
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CONTRACTOR INFORMATION:
-
LDI PERMIT
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RUILUINf. ADURESg:, c
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PC:RMI'1'NO.
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W /V &-rL .00090093
OK'NEWS NAME:
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APPLICATION SUR DATE
mi -04, sui
09113/2000
UNIT:
SANITARY NO. CONTROL NO.
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ARCHI'I'ECFAiNGINF;ER:
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BUILDING PERMIT INFO
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RI.UG 'ELECTPLUMB MI;CH
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LICENSED CON DECLARATION -
lob D0SC1'Ip11011 - •
I hereby nsedunder pr
That 1 am licensed under provisions of (commencing
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0gmf nsChapterode,
with Scction]O(p)of Division3of the Business anti Professions Calc, and my license
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is in full force and effect.
Liem,ccla„ Lien
REMODELING BATHR00 HEETRK GR RAGE
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Dec Contracnn
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ARCHITECT'S DECLARATION
I d t d be d him N.
my pl shift p ec
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OWNER BUIL DER DECLARATION
ARATION
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I by Ir ff t i pt turn 11 Contractor's l I for the
toll g (S i ],y11 9 11 I " .-Code Y ...... y
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w1 q p , t t e nxwet �du e. dvs, ,1 repo i any xtm m,
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6r wehpcnniurlde,c Law(Chatem
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p'o town, arca almanaan
Sq. Ft. Floor Area
- Valuation'
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bepaw,ppbcmt
that Lmerci enxJputsuannn=),,f isinna Of me ConOanors LicenseLsdius,
is cath, Samdon](11(11of Division3 state i agedcnsandPi. Ara vi Calc)
ode)
or that heis therefrom and the haeis Any violation
of alleged uempnt
S=ihe
31,5 b it suhe
of Sanies ]113 d it any applicant for a permit nuhjces the applicant ,o a civil penalty
to
or of name man file hundred dmmm (s50u.
APN Number
Occupancy Type
as owner of me property, or my employees with wages Cs their sole compensation.
will Jo the work, and the .sweets is not mendad or offered for sale (Sec. 7y, .
i2equlred
Rosiness and Professions CoThe Commmm'c Licence Law docs not apply to an
Inspections
owner of fanged, Who mild, or imprnves ,hc.a. and whoes o dsuch work Hower
through his own employees, provided that Such improvements arc not intended or
101 — FOUNDATION
mitered for sale. If, howeverthe building or im,rover,ent is ,old within one rear rf
nmpletion, the owner.bmNer will have the burden orprovmg that he did act build or
improve
1.02 — PIERS r .
ra punto...
. ID L nx owner of the prupro , con n lnxivaly emmracliog whh licensed .7etrucmrs to
103. — UFE R ' •
coustrnm life p,,,jcc, (see. nuq, Beenuks nal It I n.elmme Code) The Cm„mmrrre
- 104 — REBAR .
License Low does no, apply man owner of property who build.¢ or improves thereon,
and who cataractssur such pmjema wed, a aontmctons) licensed pursuant to the
105 —ANCHOR BOLTS
Comms.... Littwe Law.
❑ I an, escort order R&P C sur this reason
106 — SE4IER R WATER
`See.
owacl/- `T�-0ale �J3/00
202 — UNDERFLOOR PLUMBING
W'ORKER'S COMPENSATION DECLARATION
203 — UNDERFLOOR MECHANICAL
Ithereby alrm,vase,crudyofperj.,one ifhefall. ingdeclamtme,
204 — UNDERFLOOR FRAME
YI have and will maintain a Certificate of Consent to selfiasura sur Workers
Comperoath,n. a provided tut by Sec,mn 3700 of he Labor Coda to, he
205 — UNDERFLOOR INSULATION
Pema
ro nce or the work for which this permit is issued.
301 — ROUGH PLUMB I NG
❑ oras and w0I .,at air Worker's Cmmrnsahoa I ..... nme. as regnired by Section
3700 Lnhor Cov, for the tot his is
302 — TUB & OR SHOWER
of the perlb,mame uI the wink which par I
issued , MyWorkeCsCompennnamnInstance carrier and Policy numberare:
303 — ROUGH MECHANICRL
Currier: PolicCERTIFICATION OF EXP,MITION FROM WORKERS'
304 — ROUGH ELECTRICAL '
COMPENSATION INSURANCE
305 — FRAME
(This section need but be completed if permit is for one hundred dollars
IS I W) or les..)
306 — HOLDOWNS ' -
I certify that in the performance of,he work for which this permit is issued, l
307 — INSULATION
shad art employ any person in any manner ca as m heeome subject to the Worker:
308 — SHEETROCK.
Compensation laws of Culiromio. Data
Applicant309
'ICE 'ID
— EXTERIOR LATH
SRI APPLICANT: if, after making this Cembet a of Esemption, you should
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become subject to the Worker & Compensation provisions ofthe Labor Code, you nato
3]0 — INTERIOR LATH '
0
I1etl,with comply with such provision,or his Penni, shmev
all he counted oked.
4
CONSTRUC'I'ION I.FNDINGACENCY
311 — SCRATCH COAT
1 hereby nfrm,that there is a emnslmctlon lending agency for the performance
313 — ROOF NAIL
`p
ormw
the is nmhrmapemitjsiaa,tedrseen e
3R,cc)
Lander. Name
501 — FINAL ELECTRICAL ENERGY
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Jer.Addmaa
502 — FINAL PLUMBING ENERGY
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1 orally that l have read this application and state that me above information is
correct. I agree m comply with all city and county ordithnces and Sae lain relating
503 — FINAL MECHANICAL ENERGY '
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m
e, building coneructim, and hereby mahorim repreommaresnf this city to emerupom
the above mentioned property for inspection pu soca.
504 — FINAL BUILDING ENERGY
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(We)agree to save, indemnify and keep hamdesarhe City of Cupertino against
Imbili,ies, poquarms, case and expenses which may in any way amine agaimr said
505 — FINAL ELECTRICAL
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City in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITHALLNON801NT
SOURCE H/y/�
506 — GAS TEST
Issued by: Date
REGULONS.
W Y/ J
Re -roofs y. .
508 — FINAL MECHAN'I CRL -
St rte AppliS nmmemr Dma
HAZARDOUS MATERIALS DISCLOSURE
Wdl the applman, m rmare budding occupant sure or handle ha:amour maaral
Type of Roof 509 — FINAL GRADE
as lensed by the Ca Ndimo Municipal Cale. Chapter 9.12, ad,b
ne Health and Safety
Calc, Section 25532(0)]
0Yen ON.
1 'T Tt� �p
All roofs shall bP iW sociis TA t6 al�'r�ii riirtierial being installed.
Will the applicant or future building occupant use equipment or devices which
If a roof is instalf6 kitl`ouC f�MPii btn21h4PW SA(AW$agree to remove
emit IemNous air conaminams as defined by the Bay Arca Air Quality Mamagcatch,
Distant?
all new materials for inspection. Applicant understands and will comply with
[I Yes P(No
all non -point source regulations.
I have mad the h aallous materials requimmemrc under Chapter 695 of the
CClifiirnia Hmlth & Safety Code, Sections 255115, 25533 and 25534, 1 unde m nd that
if the building dues not currently have a,eni nt, that it is my respomsihidity to notify the
oreopuni of the requirements which must be after prior to issuance of a Can ficute (if
Occup mcy. q�
Signature of Applicant Date
roof coverings to be Class "B” or better -
Ow,,.ror amounted agent DateAll
[11117[93