01070041 CITY ofcDIOVIiSSIN PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10500 RIDGE VIEW CT LSI 01070041
OWNER'S NAME: APPLICATION SUB DATE
CIENA CORP. 256 E HAMILTON AVE 07/11/2001
( PHONE: SANITARY NO. CONTROL NO.
p (408) 370-1970
lu O O ARCHI TECTIENGINEER: BUILDING PERMIT INFO
EBLDG ELECT PLUMB MECH
y. L_7 LJ L_ 11 1_.I
LICENSED CONTRACTOR'S DECLARATION
p z H I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
P EI C with Section]0061 of Division 3 of the Business and Professions Code,and my license, T I ,
is in full force and effect.
ad 6 ,Llcanm Clara Lie.« REMOVE PORTIONS OF GYPSUM CLG. ,
1z9 m
oa Data Contractor INSTLL T-BAR CEILING.
Fn ARCHITECT'S DECLARATION
t�O g 1 understand my plans shall be used as public records
6 O p Liaenud Professional \
yOWNER-BUILDER DECLARATION
1 hereby af0w that I um exempt from the Contractor's License Law f
t?< following reason.(Section 7031.5.Business and Professions Cade:Any ciy.ei3co• y'
which requires a permit t0 construct,alter,Improve,demolish,or Rpa V My atmenl
a3— requires theapplicam for.such permit to file o6gnedatateme
m �.
poor lssuancgalw rcqu
tlmngtslwensedi Se intro Ne pmvlstom of the Contmctud La Law(Chapp��acrr 1. .s Sq. Ft. Floor Area: p ,� nation
(cammencmg[viN Satmn70A1)of Div son 3 of the Mist esi od Pm( imes' a) l i.rss 4.. . )t1 s. ht'i4h_1°:�.) li_..t �1�0QV V
or that h is exempt therefrom and the basis for th'd alleged egemini. Any.W6llanon qqppN�.7� 66
of Section 7031.5 by any aregionpfore t sulryatthe appbmnno achil penalty- 316 U6U 4 Occupancy Type
of ata ream then five hundred dollw� 00) \\
1°lasawneraf Nap y a playe.wmh ages ,theirsolei ` -ren,
r
ec 7044._
It,do
the'wor w re is not tmrntled or Pffeif for se" - '-
Baa nos - n the Ca tmcta L a not apply m an 101 - FOUNDATI�uired Inspections
own f p y
Wind it improcj N d d h work him=)(
crib gh n m I yea yled thah ch imp t e t intended r „_,._. _. 102_- PIERS
_- ,
";oRerrd f r' If..
-ei N pro einem Is sold within
one year r 103 LIFER f - -
c mphown N Id hosl° of moving Net he did not Wild or
improveforpti f sale.) 104_ REBAR
._.nl as ow a tt eaalus IY-a tagmg wtrl - see contract oto -- - 105 - ANCHOR BOLTS
comma t the pro) .7044,Business end Prom
fessn Code:)'ITa Contractor's .I
License Low does n t apply to an owner of property who builds or into roves demon, 106 — SEWER & WATER
s and who cantrat.for such,prmjat.witha comrectorts)licensed Purniant,to.Ne. __-
Canty we.License Law., 202"' ---UNDERFLOOR
.. ._ ,: .°lamanemtunder SecB&PC for his p " . :. arc°'°" 203 - UNDERFLOOR' 'MECHANI'CAL
.
. .. ..
owMr . r .Data204 - UNDERFLOOR FRAME
WORKER'S COMPENSATION DECLARATION
" 205 - UNDERFLOOR INSULATION
t I hereby affirm under pemlry,of perJury one of the following datare ions:
301 - ROUGH PLUMBING
f, .. . '° 1 have and will dilettanti..Cenificma of Cdoseni to self-insure for Worker's
Compensation, aa-provided for by Section-37110 of the Labor Cade,for the 302 - TUB & OR SHOWER
". Perini;nadeebfthewanforaddKthispewillaid,°ed. 303 - ROUGH MECHANICAL
°1 have dad will...main Worker',Compbmmion'hosurance,as required by Section 304 - ROUGH ELECTRICAL
3700 of the Labor'Code;for Ne par(owance of the work for which this pa'mut is 3 0 5 - FRAME
issuW MY W Aces Co pansau n lnsumnce ,i cihiiul Policy number ase: .rvP _y._,u,q•u
306,:r: rHOLDOWNS ._`r . ___._....T...-,....V ial i,
ll
CERTIFICATIONOFEXEMPTIONFROM WORKERS 3O7' INSUliATION''
ENSATION INSURANCE _
I. ....-. _,..--._...-.. _._-_ _— _.-_»..__. — ._ —__......- -.....
MP
ffb 5icnnnneed not he'campleodifthe permtisfor one hundred dnuaz 30$",-'.,SHEETROCK._ ,,I:..I
ftltlolon«s) 309 - EXTERIOR LATH ,
O + sI_'certify the ef im`n< fru w'kf
,
.. .: .. LATH —"'.per
fi rwh1 hthibeSCRATCH COA
` t..).sih II nor employ..y' T ctroe Worlec pen don taws ofo D t W
APPIc t I ' - _ _ 313 ROOF NAIL _
NOTICE TOAPPLICANT If,after makingN cdrPat Tea pt you should
Z 501 FINAL ELECTRICAL
ENERGY
.__
--
mnn ma pgwm rip aroma" Nap tanmlb a d akea 502 .-=_-EINAL...PLUMBING .ENERGY.
..
^t' CONSTRUCTION LENDING AGENCY
F'� there affirm thatN a conzwcdan lettNngaency war the performance 503 - FINAL MECHANICAL ENERGY., ` .
a'h of"aa..kforwhich th rmiti issued(Sec.3Wl,ov.C) 5-0.4_ . FINAL, BUILDING .,ENERGY_„__.
L.a der's Name- _ .. . , ...... . .. _ ...
�..z Undet'sAJdma! 505 - FINAL ELECTRICAL
GUL"� I c nify,that 1 have rc d this application d state that he above "formation is 506 - GAS TEST
�+ comp 1 eg m comply lh all city and county oN n c and state Iaw relating
507 - FINAL PLUMBING
in building codurunom,and hereby umnomre.represemanves of this city to enter upon
the ab.m.mendrmcdpraK�yhirinspecrapparpy;ug 508 - FINAL MECHANICAL
^s
(We)'Sgree los a rid innerly and keep hrmleid the City of Cupertino against
Vi liabilities,rydgmems,cost end expenses h ch.may in any way accoure against said 509 — FINAL
C.1
City in consequence cifflor granting orN, Permit ` r
. AIPLICANTU11111 TpNDfANDWILLCOMPLYWITHALL�bN-POINT [sSned 1 F A I G Date
9obRCE @EGULATf XqS.,
SignmarrofApquaawcomraaw : :. ., r • .,o,k,+:. Re-roofs '�
I,HAZARDOUS MATERIALS DiSCLOSURE
Wil the appbwntw future Wlldng ace panfsme whmtdle harzttlaus narenal Type of Roof
o def cd_by Ne Municipal CodChapter 9.12.and the Health andSafety
co Section 25@l lal
OYaL,., t t .L7Na All roofs.shall be mspected.prior.to.any_roofingmaterial.bemg,3nstalled..,_.
Will the opal t mtare bmld s < p comae eq pme t devices which If a roof is installed'Without first obtaining an inspectionA,agree to'remove
emit hwardens air contaminants ss definedby theBy Area Air Quality Management
all new materials for inspection_ Applicant_understands and will comply with
❑Yds. •°No . . -
. ,. '"" • '. all non-poi"`[source iegulatlons:.,.,I ' „ •, , � ,,
1 have mad in.hitmi doua materials requirements under Chapin 6.95 of the
C 1, i.Healdh&Saf iy Cade,Sections n505,25533 and 25534.1 understand that
if the building does not currently have atenant,Net it is my responsibility to notify the
oFeupgnt of Ne oc'M ctnen,which mast beetprior to issoancepf a Certificate of "
b`c°Fahy' ' '` Signature of Applicant Date
owner pr a tho ped ngeht:
Date All roof coverings to be Class,”B" or better
4 _,. . . _• -' OFFICE ... _ . .. .. . . . ... .. . . ... ...
CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10500 RIDGE VIEW CT LSI 01070s0y41
ov�jl
E: APPLICATION
256 E HAMILTON AVE A07c/11/2001
t PHONE: SANITARY NO. CONTROL NO.
ppp (408) 370-1970
O O ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LJ L_1 I= I-1
Z rn_ LICENSED CONTRACTOR'S DECLARATION Job Description
0 Z ln I hereby affum that 1 am licensed under provisions of Chapmr 9(commencing T I .
<
Milt Section YOW)o Division Sofda Business anaP fe iomQ do cad liana= � iamfull force an REMOVE PORTIONS OF GYPSUM CLG. r
Lmenx Class Lic.p
Date Conuacm INSTLL T-BAR CEILING.
3 u,Ci ARCHITECT'S DECL
LL Dy S 1 understand my plans shall be used as pu lic records
u°i a p O Licensed Professional
as OWNER-BUILDER DECLARATION
1 hereby aRmt that 1 am exempt from the Contractor's License L.w,for the
C G following reason.(Samion]U3 L5,flminess nnJ 1'mlcuinm Code:Any city tar county
which requires a permit to mostmct,alter,improv, demolish,or repair y orudure
tpj3m-prior to its issuance.also requires Rhespplicantfort such permit to nk:asigned statement
t(b<oatmAmecishlciian8nswedithpuSiasutyiontnt]oOtWne)poiof WDsiivoisnisoonfJthoef CthoentBmucstionlesssLaittndnPseroLlgaswsi(oCMlner9
as Cutlet � s ..4Si[..-,Ft:fF:'IOOI.AI,Ea•.4,, .,,is N . 1000lffi3•anOn
m thui he is exempt theiefmm and the basis for the alleged exemption.Any violation -
of Satiom'/03 LS by any app rmit mbjects the applicant to a civil'attky
:rr rot marc dun Rse naawre 31t[Zgbpl0 Occupancy Type
❑Las owa¢roflM proper rmy emplo w' a sol mpensmioo,
-will Jo'ahe work,'end the 's not d o fiere r
ansiarns aria Prdrnrmns con ,u, a Law e t 101 - FOUNDAT IQ$hired Inspections"
s
owner of propcny Who r s art improve n,a , hod s w himse
or duan ora own empi a.provided rn r m ended PIERS
arc rce le.lr,now , h 'Id' r b. 'cat rs rola i in = UFER — -- -- -
'complexion,Ne ownervbuil c bu�en ving that di a '
improvemirpuryoseofsale.). e l[j 10 - REBAR
------ -- --- a- . _. .__.. ... _ 10 - ANCHOR BOLTS....'
co h n owner of the p(Sm.7 vm exclusively mmm essi wird lie ed attract o t -
- -
construct the limits,(Sec.]t3Ys,owner o andpm xny who
ills co The con 1 Or - SEWER & WATER '
and
whocnse waacts for splyman rwnero(pr companobuiicemei put nthto the , 2 - UNDERFLOOR -PLUMBING-
and who e.Livens for such.projects wird a cont 7 I'ccnsed pursuant to the - - -- -
LIIminxeaLi,erxLaw. �^ 203 - UNDERFLOOR''MECHANICAL
❑lam exempt antler Seb, ''S8"&P for this reason
Owar 'Data" 204 - UNDERFLOOR FRAME
WORKER'S COMPENSATION DECLARATIO 205 - UNDERFLOOR INSULATION
I hereby ofrin under penaltyof perjury one oF,tm Following declamtions: 301 - ROUGH PLUMBING
'
❑ I have sad will maintainCertificate of Consul to xv.msrre for wo k rs 302 - TUB & OR SHOWER
Compensation, ae provided for by Section 37W of the Labor Cale, for the
Performance of work fpr which this p rex i jssy a. 303
- ROUGH MECHANICAL
0I have and will maintain Worker's Compensation Insurance,as required by Section 304 - ROUGH ELECTRICAL
37W of the Labor Code for the performance of the work for which this perms is 305 FRAME
issued M orkers Compc ton Insuraae cam and Policy number ort:
c.me; - /l i9 / 3D3 Z..-. .306 -, iI-IOLDOW_NS' -
CERTIPOICATIO�EXEMP('ION FROM W(jRKERS 0, % 3 0 7 f- ?i INSULATION ' .° 't•
cOMPENSAno IrvsuRANCE . °', -_ _ .-------308— SHEETROCK
(This section ri rd not ths,sample
(SIM)or less.) led if the p m t is for oa hundred dollars 3 0 9 - EXTERIOR LATH
310 INTERIOR'•-LATH» ---
" 'I certify that_in the performance of the work for which this permit is issued,I
4all not employ any person in any manimr so as tr become subject tr the Worker% 311 - SCRATCH COAT'
Compensation Laws orcaOfomla.Datil' 313 - ROOF NAIL
-APPlicant - _ _ .. ..
"NOTICE TO APPLICANT:If,after making this Certificate or Exemption.you should 501 - FINAL ELECTRICAL ENERGY
O Cbecame subject,. Worker's Compensation provisions of the Labor Code,you must
forthwith comply with such pmvismrs orthls permit shall he deemed revoked. 502 - FINAL PLUMBING ENERGY
F66NSTRUCTIONLENDING AGENCY 503 - FINAL MECHANICAL ENERGY
I heacby a(rims that there is a constraints leading agency for the perfonrunce 504 - FINAL BUILDING ENERGY
ai > Lender's Name"- )Sec.3081;Civ.C.)
r-t Le the work for which this permit is issued,
a Q 505 - FINAL ELECTRICAL
o z L mer'sAddress 506 - GAS TEST
V O I certify that 1 have mad this application end stem thanhe above inrormanon is
m correct.I agree to comply with all city and county ordinances and state laws relating 507 - FINAL PLUMBING
O'U
to building construction,and hereby authorize mpmxrmafiVes of this city to enter upon 508 - FINAL MECHANICAL
W the.brv>meationed property for mr,action purposes,
p,,, (We)agree to save,indemnify and kap harmless the City or Caperton against 509 - FINAL GRADE / 7 `Qa
` Uy halt I t -tad t and expenses which may in any way accme against said
'z ci q erfine n mrsp mat. �51^ 0 - NA P ING
AP CAS •UN ER. S WILL Permit.
COMPLY WITH ALL NON POINT ' Issued 51 _ Date
OUR S,
ignhwre App t/Curo rr Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will d capplicamor.fume buildomaccupermstoaembamlle hazmduus material a Of Roof. .. _ _. . . .._..
as de0netl by the Cuperino Municipal Code.Chap¢r9.12.and the Hearth and Safety �p t
Cute.Oyes 25533(a)4 ""bN. ' t -
All roofs shall be inspected prior.to.any roofing material.being.installed...-,
Will the applicant or future building occupier use equipment or devices which If a roof is installed without first obtaining an inspection, I'agree to remove
emir h...Mo.,air crnumd...is as defined by the Be,Arc.Air Quality Muwgenter,
Districe all new materials for inspection. Applicant understands and will comply-with -
°res-' 0 N all non-point source regulations.
he hamNous.materials requirements under Chapter 6.95 of the
main Hen comas .25533 and 25534.1 understand that
d ng dos note nveetenant,t it it is my responsibility to notify the
'am of the equir ants must be met prior to issuance of a Certificate of
Signature of Applicant Date
Dust.oramhonzeJ agent Date All roof coverings to be Class "B" or better
' t OFFICE -
CITY ofcDIOVIiSSIN PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10500 RIDGE VIEW CT LSI 01070041
OWNER'S NAME: APPLICATION SUB DATE
CIENA CORP. 256 E HAMILTON AVE 07/11/2001
( PHONE: SANITARY NO. CONTROL NO.
p (408) 370-1970
lu O O ARCHI TECTIENGINEER: BUILDING PERMIT INFO
EBLDG ELECT PLUMB MECH
y. L_7 LJ L_ 11 1_.I
LICENSED CONTRACTOR'S DECLARATION
p z H I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
P EI C with Section]0061 of Division 3 of the Business and Professions Code,and my license, T I ,
is in full force and effect.
ad 6 ,Llcanm Clara Lie.« REMOVE PORTIONS OF GYPSUM CLG. ,
1z9 m
oa Data Contractor INSTLL T-BAR CEILING.
Fn ARCHITECT'S DECLARATION
t�O g 1 understand my plans shall be used as public records
6 O p Liaenud Professional \
yOWNER-BUILDER DECLARATION
1 hereby af0w that I um exempt from the Contractor's License Law f
t?< following reason.(Section 7031.5.Business and Professions Cade:Any ciy.ei3co• y'
which requires a permit t0 construct,alter,Improve,demolish,or Rpa V My atmenl
a3— requires theapplicam for.such permit to file o6gnedatateme
m �.
poor lssuancgalw rcqu
tlmngtslwensedi Se intro Ne pmvlstom of the Contmctud La Law(Chapp��acrr 1. .s Sq. Ft. Floor Area: p ,� nation
(cammencmg[viN Satmn70A1)of Div son 3 of the Mist esi od Pm( imes' a) l i.rss 4.. . )t1 s. ht'i4h_1°:�.) li_..t �1�0QV V
or that h is exempt therefrom and the basis for th'd alleged egemini. Any.W6llanon qqppN�.7� 66
of Section 7031.5 by any aregionpfore t sulryatthe appbmnno achil penalty- 316 U6U 4 Occupancy Type
of ata ream then five hundred dollw� 00) \\
1°lasawneraf Nap y a playe.wmh ages ,theirsolei ` -ren,
r
ec 7044._
It,do
the'wor w re is not tmrntled or Pffeif for se" - '-
Baa nos - n the Ca tmcta L a not apply m an 101 - FOUNDATI�uired Inspections
own f p y
Wind it improcj N d d h work him=)(
crib gh n m I yea yled thah ch imp t e t intended r „_,._. _. 102_- PIERS
_- ,
";oRerrd f r' If..
-ei N pro einem Is sold within
one year r 103 LIFER f - -
c mphown N Id hosl° of moving Net he did not Wild or
improveforpti f sale.) 104_ REBAR
._.nl as ow a tt eaalus IY-a tagmg wtrl - see contract oto -- - 105 - ANCHOR BOLTS
comma t the pro) .7044,Business end Prom
fessn Code:)'ITa Contractor's .I
License Low does n t apply to an owner of property who builds or into roves demon, 106 — SEWER & WATER
s and who cantrat.for such,prmjat.witha comrectorts)licensed Purniant,to.Ne. __-
Canty we.License Law., 202"' ---UNDERFLOOR
.. ._ ,: .°lamanemtunder SecB&PC for his p " . :. arc°'°" 203 - UNDERFLOOR' 'MECHANI'CAL
.
. .. ..
owMr . r .Data204 - UNDERFLOOR FRAME
WORKER'S COMPENSATION DECLARATION
" 205 - UNDERFLOOR INSULATION
t I hereby affirm under pemlry,of perJury one of the following datare ions:
301 - ROUGH PLUMBING
f, .. . '° 1 have and will dilettanti..Cenificma of Cdoseni to self-insure for Worker's
Compensation, aa-provided for by Section-37110 of the Labor Cade,for the 302 - TUB & OR SHOWER
". Perini;nadeebfthewanforaddKthispewillaid,°ed. 303 - ROUGH MECHANICAL
°1 have dad will...main Worker',Compbmmion'hosurance,as required by Section 304 - ROUGH ELECTRICAL
3700 of the Labor'Code;for Ne par(owance of the work for which this pa'mut is 3 0 5 - FRAME
issuW MY W Aces Co pansau n lnsumnce ,i cihiiul Policy number ase: .rvP _y._,u,q•u
306,:r: rHOLDOWNS ._`r . ___._....T...-,....V ial i,
ll
CERTIFICATIONOFEXEMPTIONFROM WORKERS 3O7' INSUliATION''
ENSATION INSURANCE _
I. ....-. _,..--._...-.. _._-_ _— _.-_»..__. — ._ —__......- -.....
MP
ffb 5icnnnneed not he'campleodifthe permtisfor one hundred dnuaz 30$",-'.,SHEETROCK._ ,,I:..I
ftltlolon«s) 309 - EXTERIOR LATH ,
O + sI_'certify the ef im`n< fru w'kf
,
.. .: .. LATH —"'.per
fi rwh1 hthibeSCRATCH COA
` t..).sih II nor employ..y' T ctroe Worlec pen don taws ofo D t W
APPIc t I ' - _ _ 313 ROOF NAIL _
NOTICE TOAPPLICANT If,after makingN cdrPat Tea pt you should
Z 501 FINAL ELECTRICAL
ENERGY
.__
--
mnn ma pgwm rip aroma" Nap tanmlb a d akea 502 .-=_-EINAL...PLUMBING .ENERGY.
..
^t' CONSTRUCTION LENDING AGENCY
F'� there affirm thatN a conzwcdan lettNngaency war the performance 503 - FINAL MECHANICAL ENERGY., ` .
a'h of"aa..kforwhich th rmiti issued(Sec.3Wl,ov.C) 5-0.4_ . FINAL, BUILDING .,ENERGY_„__.
L.a der's Name- _ .. . , ...... . .. _ ...
�..z Undet'sAJdma! 505 - FINAL ELECTRICAL
GUL"� I c nify,that 1 have rc d this application d state that he above "formation is 506 - GAS TEST
�+ comp 1 eg m comply lh all city and county oN n c and state Iaw relating
507 - FINAL PLUMBING
in building codurunom,and hereby umnomre.represemanves of this city to enter upon
the ab.m.mendrmcdpraK�yhirinspecrapparpy;ug 508 - FINAL MECHANICAL
^s
(We)'Sgree los a rid innerly and keep hrmleid the City of Cupertino against
Vi liabilities,rydgmems,cost end expenses h ch.may in any way accoure against said 509 — FINAL
C.1
City in consequence cifflor granting orN, Permit ` r
. AIPLICANTU11111 TpNDfANDWILLCOMPLYWITHALL�bN-POINT [sSned 1 F A I G Date
9obRCE @EGULATf XqS.,
SignmarrofApquaawcomraaw : :. ., r • .,o,k,+:. Re-roofs '�
I,HAZARDOUS MATERIALS DiSCLOSURE
Wil the appbwntw future Wlldng ace panfsme whmtdle harzttlaus narenal Type of Roof
o def cd_by Ne Municipal CodChapter 9.12.and the Health andSafety
co Section 25@l lal
OYaL,., t t .L7Na All roofs.shall be mspected.prior.to.any_roofingmaterial.bemg,3nstalled..,_.
Will the opal t mtare bmld s < p comae eq pme t devices which If a roof is installed'Without first obtaining an inspectionA,agree to'remove
emit hwardens air contaminants ss definedby theBy Area Air Quality Management
all new materials for inspection_ Applicant_understands and will comply with
❑Yds. •°No . . -
. ,. '"" • '. all non-poi"`[source iegulatlons:.,.,I ' „ •, , � ,,
1 have mad in.hitmi doua materials requirements under Chapin 6.95 of the
C 1, i.Healdh&Saf iy Cade,Sections n505,25533 and 25534.1 understand that
if the building does not currently have atenant,Net it is my responsibility to notify the
oFeupgnt of Ne oc'M ctnen,which mast beetprior to issoancepf a Certificate of "
b`c°Fahy' ' '` Signature of Applicant Date
owner pr a tho ped ngeht:
Date All roof coverings to be Class,”B" or better
4 _,. . . _• -' OFFICE ... _ . .. .. . . . ... .. . . ... ...
CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10500 RIDGE VIEW CT LSI 01070s0y41
ov�jl
E: APPLICATION
256 E HAMILTON AVE A07c/11/2001
t PHONE: SANITARY NO. CONTROL NO.
ppp (408) 370-1970
O O ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LJ L_1 I= I-1
Z rn_ LICENSED CONTRACTOR'S DECLARATION Job Description
0 Z ln I hereby affum that 1 am licensed under provisions of Chapmr 9(commencing T I .
<
Milt Section YOW)o Division Sofda Business anaP fe iomQ do cad liana= � iamfull force an REMOVE PORTIONS OF GYPSUM CLG. r
Lmenx Class Lic.p
Date Conuacm INSTLL T-BAR CEILING.
3 u,Ci ARCHITECT'S DECL
LL Dy S 1 understand my plans shall be used as pu lic records
u°i a p O Licensed Professional
as OWNER-BUILDER DECLARATION
1 hereby aRmt that 1 am exempt from the Contractor's License L.w,for the
C G following reason.(Samion]U3 L5,flminess nnJ 1'mlcuinm Code:Any city tar county
which requires a permit to mostmct,alter,improv, demolish,or repair y orudure
tpj3m-prior to its issuance.also requires Rhespplicantfort such permit to nk:asigned statement
t(b<oatmAmecishlciian8nswedithpuSiasutyiontnt]oOtWne)poiof WDsiivoisnisoonfJthoef CthoentBmucstionlesssLaittndnPseroLlgaswsi(oCMlner9
as Cutlet � s ..4Si[..-,Ft:fF:'IOOI.AI,Ea•.4,, .,,is N . 1000lffi3•anOn
m thui he is exempt theiefmm and the basis for the alleged exemption.Any violation -
of Satiom'/03 LS by any app rmit mbjects the applicant to a civil'attky
:rr rot marc dun Rse naawre 31t[Zgbpl0 Occupancy Type
❑Las owa¢roflM proper rmy emplo w' a sol mpensmioo,
-will Jo'ahe work,'end the 's not d o fiere r
ansiarns aria Prdrnrmns con ,u, a Law e t 101 - FOUNDAT IQ$hired Inspections"
s
owner of propcny Who r s art improve n,a , hod s w himse
or duan ora own empi a.provided rn r m ended PIERS
arc rce le.lr,now , h 'Id' r b. 'cat rs rola i in = UFER — -- -- -
'complexion,Ne ownervbuil c bu�en ving that di a '
improvemirpuryoseofsale.). e l[j 10 - REBAR
------ -- --- a- . _. .__.. ... _ 10 - ANCHOR BOLTS....'
co h n owner of the p(Sm.7 vm exclusively mmm essi wird lie ed attract o t -
- -
construct the limits,(Sec.]t3Ys,owner o andpm xny who
ills co The con 1 Or - SEWER & WATER '
and
whocnse waacts for splyman rwnero(pr companobuiicemei put nthto the , 2 - UNDERFLOOR -PLUMBING-
and who e.Livens for such.projects wird a cont 7 I'ccnsed pursuant to the - - -- -
LIIminxeaLi,erxLaw. �^ 203 - UNDERFLOOR''MECHANICAL
❑lam exempt antler Seb, ''S8"&P for this reason
Owar 'Data" 204 - UNDERFLOOR FRAME
WORKER'S COMPENSATION DECLARATIO 205 - UNDERFLOOR INSULATION
I hereby ofrin under penaltyof perjury one oF,tm Following declamtions: 301 - ROUGH PLUMBING
'
❑ I have sad will maintainCertificate of Consul to xv.msrre for wo k rs 302 - TUB & OR SHOWER
Compensation, ae provided for by Section 37W of the Labor Cale, for the
Performance of work fpr which this p rex i jssy a. 303
- ROUGH MECHANICAL
0I have and will maintain Worker's Compensation Insurance,as required by Section 304 - ROUGH ELECTRICAL
37W of the Labor Code for the performance of the work for which this perms is 305 FRAME
issued M orkers Compc ton Insuraae cam and Policy number ort:
c.me; - /l i9 / 3D3 Z..-. .306 -, iI-IOLDOW_NS' -
CERTIPOICATIO�EXEMP('ION FROM W(jRKERS 0, % 3 0 7 f- ?i INSULATION ' .° 't•
cOMPENSAno IrvsuRANCE . °', -_ _ .-------308— SHEETROCK
(This section ri rd not ths,sample
(SIM)or less.) led if the p m t is for oa hundred dollars 3 0 9 - EXTERIOR LATH
310 INTERIOR'•-LATH» ---
" 'I certify that_in the performance of the work for which this permit is issued,I
4all not employ any person in any manimr so as tr become subject tr the Worker% 311 - SCRATCH COAT'
Compensation Laws orcaOfomla.Datil' 313 - ROOF NAIL
-APPlicant - _ _ .. ..
"NOTICE TO APPLICANT:If,after making this Certificate or Exemption.you should 501 - FINAL ELECTRICAL ENERGY
O Cbecame subject,. Worker's Compensation provisions of the Labor Code,you must
forthwith comply with such pmvismrs orthls permit shall he deemed revoked. 502 - FINAL PLUMBING ENERGY
F66NSTRUCTIONLENDING AGENCY 503 - FINAL MECHANICAL ENERGY
I heacby a(rims that there is a constraints leading agency for the perfonrunce 504 - FINAL BUILDING ENERGY
ai > Lender's Name"- )Sec.3081;Civ.C.)
r-t Le the work for which this permit is issued,
a Q 505 - FINAL ELECTRICAL
o z L mer'sAddress 506 - GAS TEST
V O I certify that 1 have mad this application end stem thanhe above inrormanon is
m correct.I agree to comply with all city and county ordinances and state laws relating 507 - FINAL PLUMBING
O'U
to building construction,and hereby authorize mpmxrmafiVes of this city to enter upon 508 - FINAL MECHANICAL
W the.brv>meationed property for mr,action purposes,
p,,, (We)agree to save,indemnify and kap harmless the City or Caperton against 509 - FINAL GRADE / 7 `Qa
` Uy halt I t -tad t and expenses which may in any way accme against said
'z ci q erfine n mrsp mat. �51^ 0 - NA P ING
AP CAS •UN ER. S WILL Permit.
COMPLY WITH ALL NON POINT ' Issued 51 _ Date
OUR S,
ignhwre App t/Curo rr Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will d capplicamor.fume buildomaccupermstoaembamlle hazmduus material a Of Roof. .. _ _. . . .._..
as de0netl by the Cuperino Municipal Code.Chap¢r9.12.and the Hearth and Safety �p t
Cute.Oyes 25533(a)4 ""bN. ' t -
All roofs shall be inspected prior.to.any roofing material.being.installed...-,
Will the applicant or future building occupier use equipment or devices which If a roof is installed without first obtaining an inspection, I'agree to remove
emir h...Mo.,air crnumd...is as defined by the Be,Arc.Air Quality Muwgenter,
Districe all new materials for inspection. Applicant understands and will comply-with -
°res-' 0 N all non-point source regulations.
he hamNous.materials requirements under Chapter 6.95 of the
main Hen comas .25533 and 25534.1 understand that
d ng dos note nveetenant,t it it is my responsibility to notify the
'am of the equir ants must be met prior to issuance of a Certificate of
Signature of Applicant Date
Dust.oramhonzeJ agent Date All roof coverings to be Class "B" or better
' t OFFICE -