03020137CITY OF CUPERTINO
wµaIOr.,.,.
BUILDING DIVISION PERMIT
BUILDING ADDRESS: -
PERMIT NO.
0 R'S NAME:
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PERMIT TSB A
p r:
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SANITARYNP"_ 040 N0.
ARCHITEC (ENGINEER:
:
- BUILDING PERMIT INFO
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BLDG ELECT 1 - PLUMB '. - MECH'
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provision! of Chapter 9 (commencing
job Description _
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with Sectio 7gmM of Division 3 of the Bust!rad Profcasiom Calk.and my lice.. is
mmnibrccErceci
Lice.. Claie Lic. �p�
ADD 499 SQ. FT, (MS -BEDRM ADDITION)- '
Dam comnnCCCI¢l L
ARCHDECTS D8 TION
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"CONTRACTOR: A + PLUS CONSTRUCTION' ^
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1 underslNJ my plans shall he umg public records --
Our
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�l�'�LE�. -
LicenlcJ Pmfceliom
OWNER-BUILDER DECLARATION-'
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following Museum. (Section 7031.5, Business and Professions Code:Any city at county
OCT
which exports a pewit to construct, alcor, improve, demolish, lir repair any structam
_
O,� 200r]
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prior In am issuance. aim requires the applicant forsuch permit to file a signed statement
of the Comrsem'i license "a, (Chapter 9
Sq. Ft. Floor Area -
Valuation
that hemlicensed pursuant m the provislons
Code)
(commencing with Section 7") of Division 3 of the Business and Profusions or,
Nat he is exempt therefrom and the bests for the alleged exempnon. Any vInlaJan of
APN Number
Section 7031.5 by any applicant For a permit Subjects the applicant to a civil Penalty Or
Occupancy Type - -
not mon Nan fire hundred dollars (5500).
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❑1, an owner of the property, or my employees with wages As thchictie compensation,
3690.8043.00
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Required Inspections .
will do the work end Abe swclute is not intended oroffsred forsale (Sec. 7Da4, Business
and Professions, code: no Commerce, License Lew data nal apply to an Owner of
property who buildsorimprovesthenon,and whodoeasuch work himtelfor through his
101
— FOUNDATION
own employees, provided that each improvements en not Intended reoffered for sale. If.
102
— PIERS - -
however, Ne building or improvement ie cold within one year ofccmpledon, the owner•
builder will have the burden of proving that he did not Wild or Improve far purpose of
103
.,— U;•-''1.•+R -'
cam.), .
104
- REBAR
velyand contracting with IinnoConnmoDnm
❑1,as ruownerorct property, am (Sec. 7044,ProlmrtywhoWidsorITheConnector)Li-
Business
datan
- '105
— ANCHOR' BOLTS-
coconsese c tapply.oanowneror rop thereme. And
rimt to the COat1CW'6
whoconwdounolapptymanownerofpmperty who licensed
who contracts for such projbcta with ecanweroKa)licena pursuant to the Connector,
106
— SEWER'& WATER .
Ligan. Law,
❑ l un exempt under Sec, . B k P C for this moonDAM
x202
.-'UNDERFLOOR PLUMBING
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203
).- UNDERFLOOR MECHANICAL.
2'04—
UNDERFLOOR 'FRAME
WORKER'S COMPENSATION DECLARATION
I hereby&an under penally of perjury one of the following tlalanRons:
20.5
—'UNDERFLOOR INSULATION
01 ham and mill maintain aceaircamoiConsent m.If-laanmfor wmkeeseompe..
301
- ROUGH PLUMBING
sation, as provided for by Section 3700 of the Labor Code, for the performance or the
3 02
— TUB & OR SHOWER
work for which this permit Is issued.
InuBo
303
!— 'ROUGH MECHANICAL '
❑ I have and will maintain worker, Compeniadon hu unnce, As red by Section
7700of the Labor Cote, fur the performance of the work tar which this permit I. Issued.
304'
— ROUGH ELECTRICAL
My Worker's Cmn nsatloninsumenceca rand lirynumherate: ID^
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305..;-.
-FRAME
Ca r CERTIFICATE OF EX^M ON FROMORKR' ERS'.
306—,.,
HOLDOWN.S.
COMPENSATION INSURANCE
307'-_
INSULATION'
(This section need not hccompleted it the permit is income hundred dollar ($100)
308'
_.
1-• SHEETROCK''
I sanity met In Inc IMrraraboom or the weak roe metra thi! pewit le issued. I.h&I mat
3 09
!._. EXTERIOR LATH
employ any person in any mannlrsm La to become subject to theWorlao,Compensation
310
— INTERIOR' .LATH, { '
Laws of California. Dam-
311
313
- 'SCRATCHL COAT
f
ROOF NAIL
Applicant
NOTICE TO APPLICANT: If. after making this Cmdricate of Exception, you should
bmome subject o the Worker's Compensalian provisions of the Ichor Code, you must
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forthwith comply with such provisions or this Permit shall be deemed revoked.
501
FINAL ELECTRICAL ENERGY
" CONSTRUCTION LENDING AGENCY
502
',- 'FINAL PLUMBING ENERGY "
I htrcbyafOrm that there is a construction lending agency for the runfurmanro Lir
Me work for which this permit is issued (Sec. 3097. Civ. Cd'
- ' "503
r� —'FINAL MECHANICAL-ENERGY
Le ndel's Name
504
:505
- FINAL BUILDING.ENERGY
- - -
-. FINAL ELECTRICAL'
Lentler's Address,.'
1 certify than have mad this application and stare that the above Information Is
correct, I agree m comply with all city and county ordinances and rase laws rclating to
S 0 6
— , GAS .TEST
building construction, and hereby amhorise representatives of this city to enter upon the
FI&9IN!
above-mentioned properly for inspection purpD.L
(We) agme to save, indemnify And keep hawle s the City of Cupertino Against
j liabllltla,judgments, costs and expenses which may in any way meet against sald City
0 8
FIAL '
in consequence of the grentlng of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
5
Issued by: 5
Date -
SOURCE REGULATIONS;q
/� n
Re-roofs'
Type Of ROOF
NAL PUBLIC WORKS
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em514
Ig of ApplicantoConsoman Dem
HAZARDOUS MATERIALS DISCLOSURE,
Ill the applicant o, furan building ..Pa., stare or handle haesrdous mamdsl
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as defined by the Cupertino Municipal Code, Chapter 9.11, and IM Health and Safety
mle.genion 25532(.)?
oY t$�a
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed
without first obtaining an inspection, I agree to remove .
Will the applicant Or furture Wilding occupam use equipment at devicas which
emit Insurance; air contaminants as dlfncd by the Ray Area Air Quality Management
all new materials for inspection. - r.
District?
I have read the hnaNnus th"aWsmetWo m ate under Chapter 6.95 of the Calimr
nuHealthA3&ctyCode,Swams255(15,25533md25534.1udemwdthutfthe building
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docs not currently ham a Mount, that it n my responsibility m ufy the occupant a Inc
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qm mcnmwhichmustbc !Fact iilsuarceafaCeruwia aclp��S�
,Signature of Applicant
�`'. ^Date -
All roof coverings to be Class "B" or better
mctarauthorized agent Dam