01010090 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: VERMI I NO.
OWNER'S NAMH: APPLICATION SUB DA'rE
�FpONE: SANITARY NO. CONTROLNO,
41 52742917"A
C z ARCHITF.CIENGINEER: BUILDING ITRMII'INFO
BE ELECT PLUMB NIECE
FNj LICENSiDCONTRACrOR'SDECLARATION Job Description
O 1 hemny vffim,Ihm I:un licen.wd under provisions of Chvp it v(commencing
F=(= with Section VlXXBof Diviaire 130f the Rusinessand Prac,,ions Clde.andmy license
¢aC E is in hill rad and.ff", 2'
�0 W a Dole m,', �_ Lm.N UPGRA OBEY AND BOARDROOM, .FINISH U
w 3° lain cnmm"nr-uttl4'G
ARCH]rECI"S DECLARATION
I understand my plam,holl be used as public evened,
C
ri
w CLiwnscd Pn,lcs,innal� /
OWNER-BUILDER DECLARATION
—m I hereby.(tiro on I 1 eBunir from the Cnntm"C', Any c Law for the
r
Mad,
mown(Section 011.115.Baine„and ve,chniol Cavc:Any city or eoumy O/
2 ca ure
price
eh its tiiur a pundit re aemweL niter,i applicant foroI dmnu,Gsh,ur repair o d state ent
w. that he slicened sAm rt4t)beres noar;otheCehlwnn Licetilse LawAsmtemem
- that heincing:.fpmmmann7000)ofiris,n3ofth Businc%%ieenwhwonsCleen Sy. Ft. Floor Area Valuation
(commencing with t mivi pa10)ofhe basis 3 of the Il alleged
x and ionfAny vi l,vel
or ihnl he is exempt ihcnlmm and the hnxi,tis the alle6eJ b,cn,ptisan.Any violation
of sectio,lot 1 5 by any applicme ron
e 1,pnnnit ntlbjc,t,the apocnnt ,a civil I,enaey
of notal III..five moored dollars($500). APN Number Occupancy YPe
❑1,a,owner of the property:m my employe,with wage,as the r,ole.om,cra ai t
will do mam h
e work,and the,o"oler Intended or offered leweed Inspections
sale(See.OW4, c
Ire and Pock, ,code:The c,mtraom's Acce,c Law Linea all onply io an
9
weer of me,c ny Who build,or in,prnvc,daml add who does such work himself
of through his oxo employees.provided mat such improvements vin na intended ur 101, — FOUNDATION
offered for sale.If,however,the building or improvement i,%old within sane year of
�,.plenamwm
plena,life one,hailder will have e hoolcnor pboiag Ism he did mm build or 102 — PIERS
nso lar n aTi,s oave.).
EI 1.as ownendthe pmpeny.am villasvely eolural with licemvd comm"onto 103 — UFER
eon,tmct the project(See.7I114.Baine,,sad Prefe,.mn,Code:)The Contractor 1 104 - REB A R
Liced,o Law Ase,not apply road owner of property who build,or impmvm,thermn,
intI won.more",for,ach project, ,In a.minant o.(,) licensed p.... I to an 105 — ANCHOR BOLTS
commen",Licere,Law.
❑Iamesemplunder See. B&PCforthi,reaaon 1.06 — SEWER R WATER
owner man 202 — UNDERFLOOR PLUMBING
WORKER'S COMPHNSAT ION DECLARATION
203 — UNDERFLOOR MECHANICAL
lhcmbyaffi nundcrpenalry of perjury one of the following declarations: _ 204 UNDERFLOOR FRAME
—
yl have and will a amndo a certificate rel Consent it, cEhaibsurc lar worker,
—lop...allmn, as ,,),filed lof by Seville me Labor Code 37k) , Ibe he 205 UNDERFLOOR INSULATION
perfurnarec o1'the work to,which ibis pem,it i.,i.ewed.
301. — ROUGH PI..LIMBING
Mil I If
heJ aserCintainor the VCnananCe ionInsurance.r required by Section 302 — TUB & OR SHOWER
9 ml'the Lubar Cole,lar the Imrfnnnunee nr the send li,r which This permit is
issued.My W..ker,Clou „aao ln,mometair i-r andPoficyanotheror,: 303 — ROUGH MECHANICAL
cmenl^��x(`IFI. U." s"ne" No:yVe2—b'21.Ob�ti to
CERTIFI. IN op EXEMPTION FROM WORKERS'. 304 — ROUGH ELECTRICAL
COMPINSAI'ION INSURANCE 305 - FRAME
ani%section need net lMcnmpletesithe lincitvnoonehundreddonms 306 - HOEDOWNS
(SHX1)or h,,.)
I mal in an neaonan col he veork rte wbi.o if, call'o issued.) 307 — INSULATION
shall nm employ any erwd in:any nonan a,m become,abject to me worker; 308 - SHEETROCK
Compensation Awa of Coalition..Daae
Applicant309 — EXTERIOR LATH
NOTIC]"I AI'PLICANIt IL.Tier making Ihls Ccnifcme mf Exemption,you should
Z b.eonfeau,moods,W..ka,Comnauaooni:od... nxnrmnLab mCode.yen mom 310 — INTERIOR LATH
O O Ilmbwd,comply with such pr..i iotas of iii,permit small redeemed revoked.
z 311 — SCRATCH COAT
VI
CONSTRUCTION is U TUN LENDING AGEge c'
I hereby wofifionhich his perm i,v maMmamn hording agency far IM1e perli,mmnm 313 — ROOF NAIL
I the r,N lie which nth permit is innmA LSuc 3119],Civ.C.3
y Z Under',Name 501. — FINAL ELECTRICAL ENERGY
� Z Lcndcr's Addles,
Icertif n Ihav�ereadtni,a r t ' Imethmn,nmsweinfmneffort is 502 — FINAL. PLUMBING ENERGY
UO y, at ly ad manors
W. torruild ggieemcmnplywihereby ymrd.00niyordinaaeolto,melow,i,tpon 503 — FINAL MECHANICAI. ENERGY
O t.7 the alb-caem,tionamnand y]or usutimrvcnprosesnmivea rel ibis city menter spm,
y y mm an (We)igieemoove.ny ,firmly ndkepharmle 504 — FINAL BUILDING ENERGY
a, e. ....gnemsnvc.indemnil y and kcepha"my'n the wayacmof en,aim,t ,ad
m B: nst
mnoie,.imlg' ,macspea..<wmahm,tymanywayaamea6ainasmd 505 INAL ELECTRICAL
U 61
A�YYLICAs II `ARU WILL C( -
I ,gnfd,i.is...... YWI'fHALLNO 4'OI T 506 BIG- TEST 29--0
souncE Issued by: Dale
siKaam ""' ".,I me lar Da= Re-roofs 508 — FINAL MECHANICAL
sen the apNic m�r Em n babl lg reve ole nc mhanmc hvanlnu,mutenvl Type of Roof
a,aehnedth the Cnpcmould unclad cave,chapter 9.Izalm me Tleaen aha sareD 509 - FINAL. GRADE
Code.Seen 25532(u)! ((,,
' wv. xNo All roofs shall be ingte� pfif;WAry?i�AV1JkQal being installed.
Will the applicant(it future building occupant um equipment of dcvivis which If a roof is installers 4hout fF4NlAbiniR�L%[iX4PecW6hR _14rce to remove
ae
h
emhazardous air commitments as akfrteJ by the Bay As An m1
Quality Ma6emmv
o itazf,,� all new materials for inspection. Applicant understands and will comply with
❑Ye, k10 all non-po' cc regulations.
1 have read the Avreniou,materials requirements under chapter 695 of the
California Health F Sale,,Cale.Sections 255115,25533 and 25534.1 understand that/
it the bei)ding o unm have a tenant.that it is my re,pnsibi lily to noti by the -
e c'efe mf which moa he an I prier to i„nalso of y Clintate it
Occupancy
Signature ol'A Ii, ret Date
awdern :,ntnmd..d ben [)life All roof coverings to be Class "B" or better
OFFICE