03030060 OF CUPERTINO "- `°^'' `�
CITY
Blnr.mNc D3vIs1oN PERMITINk'O, M no , �
a t gam'
BUILDING ADDRESS: PERMIT NO.
'ARVIN DAVIS CONSTRUCTION
PERMIT L6u
S NAME: 1.450 KOLL CIRCLE
RAUCH HAROTT) T.
E: (408) 975-0200 SANITARYN . ENO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLD() ELECr PLUMB 'BCH
;pp LICENSED CONTRACLOR'SDECLARATION Job Description -
vd 1 hereby affirm the I em lieewed under provisions of Chapter 9(commencing
with Sectio DlWrion]af dre Buri Profe in at" lid mylicevc i[
n inrullfo ea I,^KITCHEN UR612A$EADD BATHRM/SKYLIGHT
�Z L cenfail f Lic.
C factor
ARCHITECTS DW4ARAnON
9x I undereend my piano soil be galigAfolgic record[
7mom 3;1
[ID[ Licensed Pmfeai0wl
OWNER-BUILDER DEC AnON
M.Cm
CDC batch, M.on I em exempt Imre ontnn0ra :A.y.law for the
CDC o which m moon.(Sadat 71D I3,Burincu as :Any A y or ra My
lure
5$ which JU issuance,
spvmlt m conmm�,alter,hnpmss it,lir repeig ed atnnen
b� pkmmlucensedalsu requlme tooApplicantToms ad' L=rrit to ;=Lx signed statement `'
gzG
that hclallansed pursuing epmviriow of theC cm' IJanse Law(Cbepur9 Sq. Ft.Floor Area $2 �I1aL100
.�
that
customshomfm7land orbailofr the
Nc n emton.AnyonsCMC)of 1l UU UU
Nat he 1s exempt therefrom and the Basle far die Wle a exemption.Any violation or
Section 7031.5 by any applicant rar a permit Subjects the oppllem to A civil penalty of 39MI!Jlftf� 0 0 Occupancy Type
not mart than five hundred dollen($700).
❑I,as owwr of the property,ormy employees with wages AS their Sole compensation,
willdo dawak.And lbeslractufe 4notinunded woQemd far Sale(See.7044,Busineu — �J+O1 - FOUNDA PII Inspections
And Pmfoulotu Cade:The Compactors Lhaae Law data wt a m•sun f -
pnpertywholudidsosimpmveathereon.and who does,tubmikhl If terogh 1 2 - PIERS
own employees,provided that arch lmpmsemen o hen- Imsala!1 —
however.uwbunding ortmpAvememig'Aldwit�ea e el. .rar- m I d _ . ! l: 3 UFER
builder MR hero the bas or pmW it"I 1 wt Id or r .t.�'4 - REBAR
ale'). 05 - ANCHOR BOLTS
01'..
1,..owner of Ne grope y am exaluriw)a uavi with II 0 coon
[onstructweproject(SecJdgl4.BushieaaM lo ad,:)The v es U.
106 - SEWER & WATER
who Canonical
such apply nowwfar prrt my I of imp therew,ad. 202 - UNDERFLOOR PLUMBING
cease Law
does notnacpply to • 'tha can' r(s)I u.,I the Cwualord
Liana law. y 203 - UNDERFLOOR MECHANICAL
exemptunaer Sea !- " .B&P C fou this reason 2.04 — UNDERFLOOR FRAME
WORKER'S COMPENSATION DECLARATION 205 - UNDERFLOOR INSULATION , /
1 hereby M.under penalty of perjury tracer the following d clarmions: 301 — ROUGH PLUMBING
❑Lha.and will maintain aCemlinu of Conant m self-Insure ror Workcr'[Campen- 302 — TUB & OR SHOWER
utlon,as provided for by Section 3700 of the Labor Code,fou the performance of the 303 - ROUGH MECHANICAL
wah for which this pefmh i[issued.
❑l haw And will maintain Wekers Compnunion IMAM ,a resulted by SCC1w 304 ROUGH ELECTRICAL
nm of the lamrcaa,for the performanaafwewokfar which this permiti[mued. 305 - FRAME
My Workcrs COmpnadon lnsunmm rtiv end Polity nu be am: 306 - HOEDOWNS
rler.� PoRry NO.' S
CEKTI^ICATEOFEXEMPnON 'WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
lir lea.)
(This Section and not he completed It be permit le far one hundred dram(5100) 309 - EXTERIOR LATH
_..... .. .. ..... .. ... 310 INTERIOR LATH
I ceNfy that In the performance of the work for which this permit is logged,I.hill not
employ any person In any manner so AS Co became subject to the WMICCOSCampewadom 311 — -SCRATCH COAT
Laws of Ca1lfornla.Dem
Applicant 313 - ROOF NAIL
NOTICE TO APPLICAND If,SRv making this Cenlficate of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
became object to the Worker's Compensavan previsions Of we Letwo Cade,you mail
.JZ forthwith comply with own Provisions orOut permit hallbedamcdrevoked. 502 — FINAL PLUMBING ENERGY
z0 CONSfRUC]ONLENDING AGENCY 503 - FINAL MECHANICAL ENERGY
p Ihereby amrmthat them isaconstruction lemmngagcwyfor the perfomnaaaf504 - FINAL BUILDING ENERGY
C>
be wort fur which this permit Is Issued(Sce.3097,Civ.C.)
W^q Leader.Name 505 - FINAL ELECTRICAL
a Z Leine rma
aAaes 506 - GAS TEST
U Q I certify the Ne th
I hew read this application end u the above information Is 507 - FINAL PLUMBING
s. Cornet.I gree to comply with all city and county urdinswes and mm laws nelating to
OU buildingconsuuedon,andherebysuthorinmpreaentaoiveofthiscitytoAmeruponthe — FI&aNG ICAL
L2t .hove-mentioned premny for inspection purposes.
(We)gree to aro,indemnify and keep hamlea Cupertino
the City of agaisl 09 FI n.r y liabilitit6judgmenu.coNadexpense,which mryinany way am
cegainstaid City 5
V In consequence of the grating of this permit.
�AP LI ANT UNDERST AND WILL C Y WITH A -POINT Issued by: 5 Date
SO REOU}.A710
Df�� �D Re-roofs
Signature of AppllanUContncmr ��
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the appliunt at future building occupant.tree or handle haardoai mile"
final by lire Cape no Municipal Code.Chapter 9.12.and the Heal aid Safety
swoon 2ss]z(e)a
[3y., All roofs shall be inspected prior to any roofing material being installed.
Nn
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an in I agree to remove
M
ILhavafenus air comm u as dcaacd by the Bay Am Alf Quality Management all new materials for inspection.
ict?
❑Yet ❑
I have mad the hearkms meuriels remommen s unde,Chapu,6.95 of the Celifnr-
ctIN k SafelyCodc,Section 25505,25533 and 25534.1 un Iona nlfdre hulWing
j curemlyheseatenantNetithmymapewlMlity m nn t Oct. ant of Ne en yNlch2n et 'oraloguaceaeCekOwu9of cups Signature of Applicant Date
Owner or auNorbed egem "� ,D All roof coverings to be Class "Bt'or better