01030101 CITY OF CUPERTINO CONTRACTOR INFORMATION: -
]BUILDING DIVISION'. PERMIT -
RU1LDINIADDRESS: - _ - PERM]-NO'
0101
OWNER'S NAA(E:l 1 APPLICATION SUB DATE^
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SANITARY NO, CONTROL NO.
IIONIi: • .
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ARCIITI'IiCTl13NGINLEl2: BUILDING PERMIT INFO
p NLDG 'ELECT PLUMB MECII
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7� LICENSED CONTRACTOR'S DECLARATION .lob Description
n,n sof Chapter con
]III z ode, n li n
Increhy.IErf that n p p (contenting
F J -with Sanaa have and
D;v'�iinn3of the lfu'incs,and Pm(eninnsCNe,and my license - -
Z III
m Is m full force and elTect.
mwa Lmc,I,ecfa„ Lie.« INTERIOR .REVOVATION INCLUDING:'
.�serLLQ, Dane - ARCIBILCrSfdULARAT[ON '. REMODELED KITCHEN:' & BATH(S) .
t 0"g 1 andenNnd my ptms'hall be ascd a,ramie record.
f NEW,.WASHER/D,RYER, ,NEW. WALL+A/C,
Lu,n'al 11�y OWN]It 111111 Ill It DI CLARATION
u� ur 1 1ferehy affirrin ILII I he C , I :I dre '
t$�' Ii,O b .(ge l'
7031.5.8 . d P f..- .Coal A y y canny
+ S D 'Ifleb as pc t lo 6,jaca. I, ' pro,e,haral repairY truuurc '
es es ,in
I I I 4 :Ih rrl ,1 hpe II fl .b cla¢•n¢m
(cII Jp n the ill fll C 1 , L W for,Coag n n�LED - Valuation
(c,nmennngwd Senon71theDivl. nlnf,ne Basin JP I Law(Chapter
t�gtl`p,1J
of Section
ec he 7031.5
b any
applicant
p li:nA,he haus Inr,he vo,the e,enpnt to Any l roultn -
lotouinnethan iv anlodredcallars( pcnni,wbjccs the applicant lnucivil lxnal,y' - OCCIIp(mcy Type"
• nr nm marc than ave nandred npu:lr.fssw). 9��'lll}I17)bG�o O.�
01 flh p ,as Y ply ,h b In pc,'f _ ,4 4 -L - ..
rill I m k d m , I d 1 rc d l 'I (5 7144 - Required Inspections
B .IP fC I1 C t L eL I - ,atoll,I n „
ow flao,caly Who faild, (KrOlan,rod who doo,sold,o kl` II + ;ll
or J gl h' M r I' that p n I , a '��A� 08. 00 •'
dived for,rle If,boat du lnld ,b nrnpfovcmenl nn ld will i ,ey;col '
n
nnl,lelian,the nwner-hail&r will hilae(he bunitn orpmNng Ill.,Ill.,h,dol nal build or -
Far P No.-al. - -
�. m p par' ern lr m , s lnT ac Irae,nis 101- _ FOUNDATION , .
a c,,h pri t(se 7(wf Busiril andProfessions CW )The Con,ra.,nr> 1.02- .PIERS
iverve Law d cs no,apply, rtwn r of property who hold p 'c,them,..
and who contrall,for,such project%with a cornmelood'licensed pursuant to,he 103 -— UFER
Contractor.License I aw.
❑ -
Ian I,, �1 S B&PCnor Ilia c.111. 104 REBAR
DwnrLD,e '. 30 0� 1.05,,— ANCHOR BOLTS
A�r R'81r<b1ClT16pYif ] ECL Ra 4 a 11216 -,SEWER ,8 'NATER ,
I h,u,b,ifrnn n�k-!Jplaln�l yyol wr,in,oneuf the folh,win,edia one:. •
202 — UNDERFLOOR PLUMBING
bac -
I I and will maintain a Cirllticale of Conseni Io sell-hl liar Worker•' -
olnpi lean, a, pro,itad for by Seehan OW) of the Labor Craft, fn the 203 = UNDERFLOOR MECHANICAL
hera,rmao«alit work felt lam,il i,]..ted. 204-.-., UNDERFLOOR`FRAME
❑Ihave and nalmaionlnwmkerrCampea,.oaahis..na.a:n'vniredbySvono 20S '— UNDERFLOOR INSULATION of,he Llf+or Crile,for the pvarrnnuit nce of,he work for which this Fern is
„rod.My Worker,Compen.atnn,.,anon•Corrie,a ad Polies nnmCe,are: 301 — ROUGH PLUMBING'.
Cm,ler. Policy No.:
TUB &' OR 'SHOWER
CERTIFICATION 01;EXEMPTION FROM WORKERS' 302 —
COMPENsmioNINSURANCe - - 1 303.•-„ ROUGH-MECHANI'CAL. .
Ism,cla are,dfulIll tollNln,il I htpe-nlaI,forooeItllllledd,,11arse 3014 — ROUGH ELECTRICAL
(510111orlcs')' ,
305., FRAME
l an fr]hat m ..f f' v III k f •h II pe 'tissuedke 1 - -
".hml a emptor any person o any I I , In I¢vr me,ablee,la the Workers' 306 — 1101-DOWNS r . ..
cnnpen'a,roo Law,nfcto,ni..oaten 1, - -.
Applicant 307 .” .:INSULATION
N(YI'ICETO APPLICANT,if.After making this Certificate of F.,emp,inn you should -
heemnesubject to the WorkeesCampco,dionpra.i,ionaoftheLaborCoie.You bona 308 -- SHEETROCK '
O 0trtthwi,h comply whh rich provision,or Iris prrrail hall he deemed revokeJ.
'z 309 =+EXTERIOR .LATH'
F^ to - CONSTRUCTION LENDING AGENCY —
04 In ny or.,t „h o druclio.I...din,aganeyt,rthep,ionau,c 31.0 -INTERIOR ,LATH
,III ,b r 'h l this pe I ..i....it see 3097 C v C) — .
i, vbllu o 314'. SCRATCH' COAT
UO flat n' o Ippl f d „ mal,l n 7 313 —' ROOF NAIL,
44F a I.Igmel,,emnplywid,.nill, d'annlyorana d ,are Inw, lning 901 —' FINAL ELECTRICAL ENERGY
Or, nhnddingcomlmction,andhercnY:n,moi,ereprestatanve,ofmi,I'll.enternion 50G' — FINAL PLUMBING ENERGY,
FW Bic above awationed property file in ver ion p.po,r�• -
F• ("It)ag,,c,e nae,indemnify and keep har less the City of Collegian.,ain't
fn tamB,ie,.;adgmencosts atsaid D —
. 503 FINAL• MECHANICAL ENERGY
U Z City in consequence of the grunting of this Krunt. 2
o a
APPLICANT UNDERSTANDS AND WILL COMPLY WRH ALL NON-POINT Issued by: r .504 — FINAL BUILDING DPERGY
SOURCE REGULATIONS. + "
Sigomarom A,haanticmnncnr D:I,e Re-roofs 506 GAS TEST
HAZARDOUS MATERIALS DISCLOSURE.
Will a,capplia,nlWfunlltmwdingne<npamoore...finalthn,:waa,Imllenal Type,of Roof 507 — FINAL• PLUMB TNG "'
: 11 ih> lle C.Penue,M ''IC CIr,o 9.12,rod'he livalkh andS-Its '.
Code,Srs,li 255.12() 1 p!� Mp f� -
❑r: [3 M, All roofs shall be ti 'ted ribf'�t Inny'ft70 � t�i l'bung installed.
Will the appl.nla,fmure haM,gncc,mao, ' gapn alor dc,ac,Lal ch' If a roof is installc5 haut Frk!Wainr�tiFf l ispp�e�etion, ]agree to remove
ini,haamdous air contaminantsa,defied by the Ray Area Air Quality Managennn (RhtF1i B@IbdrJP64'xls and will comply with
" all new materials,�O13�spzeti6r�l�r pli
❑Ye. ❑Noall non-point sour.•§jagulatitingNAL PUBLICWORKS
1 � "
` I hie read @t haeanloue materials requirement under Chap,e,6.95 of Ile
California Heath d Safety Caole,Section,25505,25533 and 25534.1 understand that
,he hu lJng Jns , rrc fly lane t th,l slay O :nilly inn Ify the - -
Ut finerc -' Ichn ata. ,p',r lot I,Ce„f t f '
e
yF�"`y Signature of Applicant Date _
'Allroof coverings to be Class, "B"'or lieLLer a -
Ow9 vgu Date
OFFICE..