00090077 CITY CURT
BUILDING DIVISION
PERMIT CONTRACTOR INFORMATION:
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BUILDING GG 1W9 RAE LA PERMITM00090077
oWNE SNHN&TA YESHWANT D AND ILA APYLICATI upi c/2000
IONI?; SAN)"I'ARY NO. CONTROL NO.
�Q C Z ARCIIITEGT,IiNG1NIiliR; BUILDING PHRMI'I'INFO
- Rl ELECT _ I'LUMB MECH
a� CI CI IJ 6_1
Z O N l I.ICIiNSEUCONTItAC'R1H'S DECLARAI(1N Te Job Description
OZ O Inemhy adbum;hal1and licensed.ndsr prnvinio is or Clntpmr 9(eros ting
tu is insarmtnandefanti.slan3alm,Bmiuss...ngLnGky,.ycm 'n am>Iianse 497 SG!. FT. ADDITION
s m=,J
is n,full n,na am enter, and�h/VK�
a z 2 Licca¢Clnsw Lic.M
i`a Dole Cnnl.tnnr
"��3 a obi ARCIIITIfCT'S DECLARATION
s' O 4 ly adandplans c all be used a.politic mcaN,
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¢O O Liacnsu Yn,k,xmnal j
OWNER BUILDER IIECLARA'1'ION
a❑ 1 hereby affirm that I am exempt from the Contractor's License Law for the
F Z< following rmxon.(Section 7031.5.9minens and I'rofcaiom Cede:Any city orcounty
5 F O wI M1 :a vrimil I m",afte,improve.dannolish.u,rani,mr,streenre
a, se pr. 'I y ' .th ppl. tl hps t fl g d statement
c. 'hat he is licensed monam to the provisions oftn Coni License La (Chapter 9 S FL Floor Area u�t'
- (can ecn,wthSee n7000)ADi.sonSof;hslhsna, ndpool .. no Code) 9 !
lir hor he is exempt Il,"d'ro;i and the haQ.for the allege)exeninion.Any violationof Serino 7031 5 by any applicant faro penniI ann,i,els Ibe uppllnml h,a civil penalty
lir not.a.aa lima live hundred dollar,.S5100), APS N yq�tJ,g�. Occupancy Type
00
❑I,a t,the r of flit properly.structure my ensplo t m with wages u..Ihdf cola le(See,
S e,7(94,
will nc flit work,and the odeThe
is not immWM ei allLaw for anon apply tx34.
(+nems..and erty Whos tits,:the mama Lars Lindwp law dots,btu apply m an �l�e p�tr pspeetions
of phut,.who ladle o mpm pw mereo,and sent, lits such work mond.. 1.01 — FOUNll� I V
arvpmmgM1 lin own employers.or
that satin improvements me nm amended year or 0
completion,
for wk.owner r Wilder
mel have t n.impmvcm inn that
he did one year of 102 — PIERS
im,pown for theuseof wilder will have the bunters of proving that he did nm buil)or
pmse for purpose or sale.). 103 — UFER
[D 1.list rnf the property.am exclusively commcling with licensed nmtmatorsm 104 — REBAR
Ln,tmc,xthe mover(see."nw4.Business and prnfes.ios Code:)The Contractor. 1.05 — ANCHOR BOLTS
i�cp Y Law doe not apply a,an owner of progeny who builds lir improves memo.
and%nt,commas our such pmiver,with a tommcmms)licensed pursuant to the 106 — SEWER RWATER
Com mere.,I"i,eroe haw.
lamexciontinderSec. .[I&11C]or this reason 202 — UNDERFLOOR PLUMBING
('w°sr Djv 203 — UNDERFLOOR MECHANICAL.
WORKER'S COMEHNSAJ ION DI!CLARA IION
—4 k11,I 111yhl tnd aiio'.nonfall .c,nll se to c.aIddhen'x,o" g a, i 204 — UNDERFLOOR FRAME
m, IorWalker, 20S — UNDERFLOOR INSULATION
Compensation. as provided fon by Seciim, 3700 of the Labor Coals. Bar the 301. — ROUGH PLUMBING
fervor accof me work for which this pemnif is issued.
❑I have and will maintain Worker's Compensation Inwmnce,a,"mrad by Section 302 — TUB R. OR SHOWER
37(1 of are Lannr Code.for the Woramsonce of the soak fm which this remelt is 303 — ROUGH MECHANICAL
issued.M)'Wool Connpen,ation Insurance carrier and Policy mounter am: -
304 — ROUGH ELECTRICAL
Cortien Policy No:
CERTIpICA'f10N OF EXEMPTION FROM WOR KI;RS' 305 — FRAME
CONf]'ENSAI'[ON INS U HA NICIi
(This act i need not he....nd pin if he.cosh i,h,.moa hundred dollars 306 f'101_DOIJN$
ullxn.tmsw.) 307 — INSULATION
1 and,d,n in the pc,frmru.,t,oat in, ork or wend, his pprtni,is issued,I 30a — SHEET ROCK
cshall mal card,any 11-no in,toy renmcr so as to n,enate,anieel m nae Works,, X09 — EXTERIOR LATH
...........d....laws ou c.Er,mm.Date r
Applicant
N(hicr TO AI'I'LICANE If,afterm;ding this cenifioac or Hminniun.y mshould 31.0 — :INTERIOR LATH
Z bec........b,a l.,the warke,.w Compensation pm ,i.as tolow]..Nor coda.youn.,, 31. 1. — SCRATCH COAT
Q Q Iarthwilh co;nply with such provisions lir this perout skull he deemed revel n
CONSTRUCTION LENDING AGENCY 313 'ROOF NAIL
1 hereby affirm that them is a construction lending agency for the performance
� > of the work for which this permit i,issued(ser.3(Yi Civ.CJ 501 —FINAL ELECTRICAL ENERGY
i o Land°r'wAONeAdkins, 502 — FINAL PLUO'IBI14G ENERGY
Lenders Name
UO IamrythatIbase mad,tri,application ards,are m:nmeaLweinfnmmmnis 503 — FINAL MECHANICAL ENERGY
o-. e' sunset.1 agree m comply with all city and county on inanecw:rad state Laws refining 504 — FINAL BIJ I LD T NG ENERGY
O U to nodding panstmeron.and hereby umh)ri1m,m,aawdv,sm this city m enter.,a
>, tr he manymmmoned propcify h,.tnspom.,n Imrrvosss505 — FINAL ELECTRICAL_
�. 6, I Wa)agree to save,indemnify and keep hamlets the City of Culsemno agar t
.. rn nahnide..indgmeals,cads."it eapems,w1d,h may to,any way recite age I said 506_ —_.GAS TES'(
U z City hu.........ren,cof me Starting tar misery
AI'I'LICANTUNDER`TANDSAND WILL If9.Y WIT]I ALL NONT91NT Issued by: 507 — F'NAL PLUMB INC, Date �—`civ
it I-
STnalumnrAppucauv ; rdnr 1 le Re-roofs _
e ,ARDOUSMALER1A1sDISCLOSURE 509 — FINAL GRADE
Will the applicant or Imum building t,ecapam score or handle hwuNas,mammal 'Type of Roof
as Jelined by the Cupertino Municipal jade.Chapter 9,12,;and the ucahn.ad Safety 51.0 — FINAL FII_ANNTNG
Code.Section 255Raa1'! �V/
0Ya, All roofs shall`54 fnspectFcffotlit11_toRhpbdfing4iNRILNbeing installed.
Will me applicant.,.future huildineeccupnnt as,eyuip,uc,t err IcOses which If a roof is installed without first obtaining an inspection, I agree to remove
nit baea,J..s air mmamina d,a,defined by the Bay Area Air Quality Management
a,a,f! all new materials for inspection. Applicant understands and will comply with
0Yes all non-point source regulations.
I hire mai the ha,allos material,mnuimmenta under Chapter b.95 of the
Cxlil oraia Health k Safety Code.Sections 25505,25533 and 25534.1 understand that
it les hnllding dur,urn cmmmly he,.a mriad mat it i.my rey,muihility m notity the
,o,an,of the ox i.ements which pri.....iswanm Cora Ceninvue of
01Signature of Applicant Date
-— -.r-:m@rigem Dat/at/- All roof coverings to be Class "B" or better
Uwnenaa
OFFICE