00080182 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRCSS. PHRMI"INO.
OW'N'13H'S N n1': APPLICNI'[ON SUB DATE
IONIC - SANITARY NO. CONTROL NO,
O-Z ARCIIITIiCf/IiNGINECW BUILDING PTRMI'I INFO
H BLDG Ii11:.C1' PLUNGE Mlicll
H I_I I__I r .1 1_I
z0 <N
�F LIC CNtiEDCON
n,ed a OH's Il1iC 11%olCop -slob Description -
z 0 1 nm,ny umr,n darn 1 um licern,cd order nn,vi.lnn.orchnpmr n(nomom,ncmg
F,wtdu with Sectio 17000)of Divi.vion 3 ollhe 13do....and I rofcosmn,Code.and my licence
is in full home and effect.
z < License Class Lic.M
xc�C Dale Connector BATHROOM REMODEL
m 3 a m
I, ARCTEM's DECI.ARATION
F'yog Iandernmdmyplan„hAIdd.,rdx,puhl....... FINALED
ad 6 C�O Liccmed 11rnfnnional
a a o OWNI!R-BUILDER DECLARATION
1 hereby affirm the 1 um uempt from me Contractor',License law far be JUN 1 3 2001
f-z a following reason.(Section 7031.5,Rosi....unit PmB.v.ion,Code A,city or calmly
F S p which requires a Permit to construct. In p demolish,or reM y- tum
n3� Em it,it, 1' 4 roes 0—ir,licianf h wribitt rile a signed:nt nem
barn 1 Ip It (he n - ns Ifth c r n r I 1 (chapter9 Sq. Ft. Floor�ILDING+ Valuation
aotonem ,Fwd,Section 7dxndD'.�nn 3 of the Bosne.,amilofe.'t Code)
,r mal he i,catrtu deref I and me nask babe mlcged o.empnimI Any violation
of section 7031.5 by any applicant for a peril subjects the applicant to a Ovid penalty
of not mom than Me hundred dol lat,(S5o01. APN Number Occup•Ic ype
DI.asowme,of be pmpenymrnny employees with wage.a,their.old cmnper inn,
will do he work.and he,tenor,1,not mended ,,offered for safe(Sc,,70a. � .
Halls,.mal Pena-Psion,Culi,:'n,e Contmemr's License Law dog,not apply ton - . - 'quires Inspections
r of Popeny Who buil.k or improve,nc,mon,and who sax inch work blmaelf
or through his awn employees provided that such improvements are not intended or
offered for sale.IC hummer,the building or imprnement is.old within one year of 101 — FOUNDATION
completion,the owner-builder will have the burden of proving than he did not build or 'y
improve for pmpnse of les. 102 — PIERS
1, ow I'll of me proprny.:,In osema.ely mm,oahng wan 1'mmn.rd commemrs m 103 — UFER
n.lmet m,prujcn.So,.794,lo.on—and Profa„ion,C.wid)'1'1m Comractnrt, - 1.04 — REBAR
Libras,I.,dox,v futo n apply am ovise-of property wino reuilds.sr ou,moo,field r,
and who contract%for such projects with a cam rdiabO)licensed pursuant to the 105 — ANCHOR BOLTS
Cmdba s License Law.
❑l am rsm de see .B It P C forbie rea."" 1.05 — SEWER & WATER
202 — UNDERFLOOR PLUMBING
Oli 'S C'11MPE S_Al'ION UIiC1,AHA I N
I hereby affirm under penalty of perpry one of he following decluralmn.: 203 — UNDERFLOOR MECHANICAL_
D 1 have and x;n maintain a Cenifcam of Consent to wif-m.an,for workers 204 — UNDERFLOOR FRAME
Cantrenwrnn, a, provided for by Section 3700 of the Labor Code, for the 205 — UNDERFLOOR INSULATION
perfunnnnee of the work far which rhi,permit In issued.
01 havenmd will rrubmin Wokersen.u'rawlrioi lnwmnct.n,rc4wred by seer.,.. 301 — ROUGH PLUMBING
371x1 of the Labor Code.for the performance II the work for which dei,Pi Is 302 — l I_IB & OR SHOWER
i.cue&My Worker',Cnmpenanion Insurance carrier and Policy murder are:
303 — ROUGH MECHANICRL t
Cartier: Policy No.i
CIT NIII'ICATION OP CXEM PITON FROM WOR KI;RS 30/d — ROUGH ELECTRICAL
COMPIiNSATION INSURANCE
305 — FRAME
anis.aemmn meta nm be eornnpined if m,1„r...a is for are hamh,d dancers 06 — HOLDOWNS '
(S100)nr km.)
I treaty that in me performance offs work for which this permit is issued.1 307 — INSULATION
.tau not employ any person in any manner v..as in necomr sunhat to me Worker: 308 — SHEETROCK
Conars lion I.—of Cullhnnit,.Dam
Appoc:mt
NO[ICE'10 APPUCAN'I:E.uH,r atik Iii,Cerrficmc(Indstmprio^.lin..should 309 — EXTERIOR LATH
neenm,sunjecl to the Worker',Co..npenmAon nm.isio..,of the Labor Code,you nm,t 310 — INTERIOR LATH
p forthwith comply with such prwi,i...or this pans,shall the deemed revokea.
Z
y CONSTRUCTION LENDING AGENCY 311 — SCRATCH COAT
I hereby affimn that them is a conswction lending agency for the performance 313 — ROOF NAIL
of the work or witch rlik lwnnit i,tollead(Sec.3y)7.Co.C.)
0a p lwmkr,N 501 — FINAL ELECTRICAL ENERGY
a z Lcndcr'„Wdre,x
U O lnnifyrhmlhasereadthi,applicationanJuamfhattheaboveinformationis 502 — FINAL PLUMBING ENERGY
t, correct.Iagreetocomplyuithallcityandcountyordinaniandnrtelam.refuting 503 — FINAL MECHANICAL ENERGY
V rebuilding e...ntmction,^nd hereby actinium repmaantativo of this city to enter upon
beano, mcaushodp,,.,byTor impeclonpurpo 504 — FINAL_ BUILDING ENERGY
W
(We)agreeI 1 ly Ik id I the City fc p t um"oil 505 — FINAL ELECTRICAL
0. liahl e IF o I 1 1 1 1 r'Y ,he 'Y' ' Fairer.aur
O �_ City in cnmµneaeeof the giloni ng of this D.rnit. rr..����-- ' 11
SOURCANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT Issued by: 506 �TdEST Date �Q > —v
`IIFINAt
01:7Signmure of Applicant/Cnntmctm Date Re-roofs —
HAZARDOUS MATERIALS DISCLOSURE 508 — FINAL MECHANICAL_
Will the applicum or boom,holding,mop..lit 41M OT 11411(11C ho.urdous rnwadm Type of Roof
a,de@ndbythe CapconsMmni,yalCod,.Chupnm9.12.amIthe lWdthmtdSamry 509 — FINAL GRADE
Code.Section 2snxa)7 p P W1
Dtio 0 N All roots shall �CIiI ectecFl �i�ilto n aterial beim installed.
Wlufhc appncmo,fd...holding racupmn use eyuipmem or devices which If a roof is instaTI(frwiTho5Jt114ft16btRi IR&I-aT3 rns}Slcf 4x51 agree to remove
nil harudde,air c,mmuin:nma a,drGnud by he[toy Atha Air Quulhy Mane,vubdu
lisr,in^ all new materials for inspection. Applicant understands and will comply with
Dye^ ID No all non-point source regulations.
1 nave,cad the hi....namdaks teyuimmrmn under Chapter 6.95 of the
California Hrahh h Safmy Code.Section.25505,25533 and T5534.I undmstarxl the T
ifthe building does not currently have atenant,that n i..my resrym.ibility moodily the
occupant
of the re. i„m,nt.which mu, t prior In ismanae of m Crnifnvm of
Signat Ire of Applican Date
nodsrd age, �/ All roof coverings to be Class •'B” or better