01100033 CITY DNGwvmONO
INPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMITNO.
10555 RIDGEVIEW CT. Xx. 7 y 01100033
oCOMPAQ COMPUTER CORP . BLDG-6 �r A1L0/ 04% 2001
I PHONE: SANITARY NO. CONTROL NO,
w O ARCHITECT/ENGINEER: BUILDING PERMIT INTO
w— BLDG ELECT PLUMB MECH
N Q r L3
LICENSED CONTRACTOR'S DECLARATION
i7v IherebyaffirmmatIamlice,edunde„ am-nimmcfChapter9lcommcncing Job Description
'_C'° With secion]segoofni.isloa3crime Bostonsand Pmfcsdomscod ntlmylicense TENANT IMPROVEMENT.
ce se `°015, (gc'} 4 pv (REMODEL PANT R �O ADA UPGRADE)
i.z�'.1_5
Dian. Clash J'•` Llc.k� �QL .
=D a Date '�+- o S DEC A tie
o a ARCHITECT'S DECLARATION �®
—� 1 undeaand my plant sM1all be used as public recortls
3 SEP 2
a a Licensed Pmfe„inial , 2002
e, OWNER BUILDER DECLARATION
uN1I I hereby affirm but I um e.empt frim the Comractnr's Liana Law for the•
I F o fallowing eeawn.permit
to
]031.5,Business and se,de o demolish,
Code:Any city or cwmy
whichitsissuance.
ssrequires n permit re cons tet,altar,impose,h corms t or repair any structure
is.ca Priormhsllicensedpalwregithe meapplicant for Compactor's License
statement -
Riazhe mending Wit punnani in,700c ofDr,onaof the Contractor's Li anscLe,im., ode) f , .S FC,FIoor Area, Valuation
(Commending With Saiion d(g0)pf DivisionJof the Business ad Professions Code) C;i`6;,'i•, . . E , Ir. •„".,.;dry{ ;':'j['ir .
or that Be is exacpt theiefrom and the basis for the dleged dem uuon.Any violation '1100t�042 00
of Sermon 7031.5 by any oPPIic.m for a permit subjects the uppliam m a civil penalty
of nor more than five hundred dollars D501). APN Number Occupancy Type
❑1,as ox ac,of me Property.0 my anployees with wag,as their sole compensation. FOUNDATION
Will do the worn,and the structure is not intended or offered for sale(Sen.70i4, 10 2 - PIERS Required Inspections'
Business sad Pmmra
fcssions Code:The Connr's License Law does mil apply m an
owner of property who build%or improves thereon,and who encs such work himself 103 - UFER
or through his awn however,employee,t provided that sunt i vercut mems arc not on intended or
completion sale.If.how,,,me budding at urden of Prov n sold he did one year of - 104 - REBAR
improve for pro,oeeaf sale.)r will have the burden of proving roar M1e did not build or 105 — ANCHOR BOLTS
DL"ao owner al m� m' n yt�� 6 T06 - SEWER &'-WATER'
pr e y,ant exclusive vnctin o with Code:)
Co eToys to —
License me protect(See.7Baa,BusinessandPmr,hionsildsorNievesmcturs 202 - UNDERFLOOR PLUMBING
License Law dues not apply man owner with
Property when builds se improves thereon.
sena who License
for sato projects with a tommnw s>licensed pursuant to me 2 03 - UNDERFLOOR MECHANICAL---- -
Contractor's -
01 License Law.
- ❑Iamexemptunder Sec. .B&YCfor this reuson 204 - UNDERFLOOR' FRAME-'
owner Date 205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION 301 - ROUGH PLUMBING
Ihereby affirm under Penalty of perjury one of the following declarations: 302 - TUB & OR SHOWER
o I hove sena as r maintain o certificate or Consentto ser-insure for Worker's 303 _ ROUGH MECHANICAL
Compenwrmn, he ork foil for by Section 3]00 of the labor Cade, for tM
perrom,ana ohne work for Which this Pemrh is imupa.. 304 ROUGH ELECTRICAL
❑1 have oad will ntnimmin Worker's Compensation Insurance,as required by Section 3 05 - FRAME
3700 of the Labor Code,for the performance of the work for which this pencil is 306 - HOLDOWNS
My Worker's Compensation Insurance carrier and Policy number are:
ameE iid.Ae�::Ins.Ci'toPou�yNo.:'WGL9I$`I21(Ol 307k,.- ,-INSULATION ` - --;-,j-, '---'---- -
issued.My
CERTIFICATION OF EXEMPTION FROM WORKERS', 1.308"- SHEETROCKI '
._.__ .. COMPENSATION INSURANCE.' . . -- ....__309- --, .EXTERIOR LATH'--
la, - -- -`----- -----
DrAs section need not completed if m3101 — INTERIOR LATH
Elie Permit is for one hundred dollars
(alWl ohne,) •'1`
31-1 - SCRATCH COAT. ._. . ...
1 certify,that in the performance of the work for which this Permit is vowed,l
shall not employ any person in any manner w as to become subject to the Workers 313 - ROOF NAIL'
Applicant
laws or c.hromu.Wm 501. - FINAL ELECTRICAL ENERGY- .
Apphcnnt . .. -
NOTICE TOAPPLICANT:IC after making this CctifiateofExemption,you should 502 - FINAL PLUMBING ENERGY "
become subject m the Workers Compensation provisions of the labor Code,you must
O
formw ith comply with such provisions or th is permit shall be deemed msoked 503 _ - .FINAL MECHANICALENERGY
Z ”' 1 hcreh Rrm that mere is a construction NG AGENCY'a en ' - -” -
E.-� 'cOtthemiCT)ONLEIJDBlagg1da504 - FINAL BUILDING ENERGY '
K r en t B'B aY for the liedormance —
nnnEwnrketrwnimmispemmistseedls«.3B9],cm.c.) 505 FINAL ELECTRICAL
y p Lender's Name' .' . - .. . . •.... ••. _ .. 506 GAS TEST .. .. . - . ---
D1Z. Lader Address: ' . . _ _ - -
U O .I tartly that 1 have read this application and state that the above information is 507 - FINAL
PLUMBING'-correct.I agree to amply with all city and county ordinances and state laws remang 508 - F I NAL MECHANICAL
O'V to Wilding construction.and hereby authorize representatives of this city to enter upon 509 - FINAL GRADE
the above-mentioned u. irvicendtarinspectionpurposes.
r d ce,pidgreetu ave.indemnify and keep harmless may
City of Cupertinoagainst
said 510 - FINAL PLWING
(n liabilities.judgments,costs and expenses which they in any way accrue against said
U Z Chylncomequenceof In gra t ,.fth' mit. . .-.. 514 - 1! WORKS
APPLICANT UNDERSTAND OMPLY WITH ALL N�N. iNr issued Date
SOURCE REOULATIONS:� N y'
Signature of AppllcantIC .. for .Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or Same building oreupom pore or haodle ha..ndum,towed- Type of Roof
as defined by the Cupeninn Mmucipti Code,Chapter 9.12.and the Health and Safely . „tee I ti
Code,Section25532(x)? . , Nn-
,-, .•3 .!a.l
All.roofs.shall be inspected.prior to any.roofing material being installed.... . ... .
❑Yes'. .. - .
Will the applicant or future building occupant use equipment or devices which If a roof is ins'talle'd without first obtaining an inspection;lagree.to remove
mit hmus air contaminants as defined by the Bay Area Air Quality Management
DvmL
istrien ��`ppp all new materials for inspection. Applicant understands.and will,comply with
oyes D]N. all non-point source regulations:,
l� 1 have read the hazardouuss\md¢riuls requirements under Chapter'fi.95 of the
califomla HealmS,safety Code.Sections 25505.25533 and 25534.1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify the
cupni of a rectal its which mons b ind mior to issan of a Certificate of
acup,mcy � 5 b Signature of Applicant ..., .. - Date
owne or t poi=ea agent ”- Date All roof coverings to be Class"B" or Better
._ .. . ...,.. ... _ .. . . .. . OFFICE - . .