00110031 CITY OF CUPERTINO
tnalt.ulNG DIVISIONPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRf SS PC:RMI'INfl,
OWNI-R'S NrUTRMF—Ei SANJtjl;lqNL) KH I H Y F _ I I ER ARhLAoc0aAIIN003 1.
IIONH: s' — EHIVIPIT— SANn'ARY4)1.�Q16 acIaN.7t;MGT'D.
1'Z0 ARCHITECIFNGINEER: BUILDINGItiRhll'TINFO
0
C U— BLUG El,li(•T I'hUMH A1ECfi
y�G lu r_I �I 0
LIC ENSEDCOMRACOWSiAICLARATION Job Description
O z= I hereby anion,ha I a,,,Ilrxnsed under provisions of Chamer 9(commencing
with Swnt.7d(10)ofDi,mon 3ofthe Rraieuend Prolin,ionv Calc.and on,license _
6
all
— is in full force and effect.
ce ¢ L cmn,a Clay I:m,d
o u Darr cDECJ,RATION
AHCIII'rF.CI"s DECLAFINISH .OFF UPPER FLOOR SPACE ALREADY RO
c °gI arderoad!myPlunsstart[sensed n,puM1llcrce°rJnERMTTTED, NOT FINISHED FROM ORIGINAL 1
tie a p p Liccnsal i'ndessinm:l � z
OWN'IiNBUI1bEH DECLARATION
u '9J I hereby ildin r than 1 ant exempt oma he Contractor's Li<enw Low ror,he
C a 1ollewing nvam.(Sce,ion 7031.5,itusincss and I'rorussiona Gslo:Any city or county
p which requires a pemir to construct.ulter,improve,demolish.or repair any structureco-
n3� prior Colnma,r.e,arq
lv,oui,cs,hmq,phemnn
n toranch Peiuulilc nsignN,uncmcm
,hill he in licensed puauant to the pnrvismm of the Co nnarhas License L,w(Chapter 9Dor Area Valuation
(commeneing with Section 70Bolof Division J of the Business and Podr"iore Cade) y.
o,r than he is ren,therelr..m unci,he oasis for me:dlrgcJ rxomp,io,,Ali,v,olminn
r Section 7031.5 by any applicant for a perms zahje<n the applicant e,a civil Penalty
moue re Iran five hmni ddnw,re(a500). APN Number Occupancy Type
01.asow ner onhe property,or my en,plorces with wades us[heir mole compensation.
wilt do the work.,toll the xhni,la,is nn,inrenArd.....front fur-talc(see.7044, Required Inspections
It and Pru eoiona Chile The Conaacar's Use..Law does nor apply mon 9 P
�rvthortnnsay,Who build,or improv,:.thereon.and who does such work hinaeB 34 2'18 031 . 00
rough hum Tployces.provl:led,hut.such imp°,en—as are not intended or
offered for sale IL however the building nr impro ratan is sold within one year of
nnplc,ion,the owner-hnlldc,will have the burden of pawing,hm hernial no,huild or
i., rptr,,wnf'a1i 101 — FOUNDATION
❑ ,as owner of It.progwrtv.:nn cxelusivdyo naaoir,w,In licensed contmemr,m 102 — PIERS
Lo swct the project(Sec.7144,Business and Professions Gdcq T c Contractor's
icc use l.nw docs not tjily or an owner of property who builds or ru'rove,ntereon, 103 - UFE R
and who contracts for such III with a con,mnorls)licensnl puuzuunl to the
contract 'el-icer, 1 04 — P,EBAPc
❑,aur .B m P C for mi.reason
uwaer _ _ Date /%-6_Q� 1 05, -. ANCHOR BOLTS
WORKER'S COMPHNSA'I'ION DI!CLARATON 1-06 — SEWER 8. WATER,
IrPrny Dolan nmmn lienally or w1jLry one oftho r..Bowhtgdcnatam,nc: CO2 — UNDERFLOOR PLUMBING
I , have,and will n irrnn Ceninc:,,e arcaameh„ ro meff.himure far Wcakerm 203 — IJNDF_RFLOOR MECHANICAL
,o,tralion. ax provided or by Seedon 37011 01' the Lan.., Code, fur his,
perfomrance of she work far which this penoil i,issued 204 — UNDERFLOOR FRAME
❑1have and wiffIrrianinWeake.,campenotionInurana.asrequired bySection 205 — UNDERFLOOR TNSI_II_ATTON'
TIM or the Labor Code,for the Ecrfnrmunce nrthe work far which this ramitis
i.ssued.MyWorke,mConnpcncationIn,urancecarrierandPolicynu,nberare. 301- — ROUGH PLUMBING
car..c,: Policy No': 302 — TUB 8 OR SHOWER
Cliff I a,jCArhON OF E%EMIT1,N FROM WOR KERS'
COMPENSATION INSURANCI! 303 - ROUGH MECHANICAL
(This section need not he eonipleted if the pe[mil is for one hundred dollars 304 — ROUGH EI-ECTRICAI_
(SHanoncxa.l 305 - FRAME
1 certify that in the ierfornarre of the work far which this pe.air is issued.I 306 — HDL.DOWNS
,hall sot emy p
ploy uarsonan ren n In airy manas m be.....re xuhj-1 u,the W..on, .
eumpen,ationlaw.areahromia.Dae 307 — INSULATIOIYI
NO[ICm
NOTICETOct ,, ICAN'I':ILCon,witaking nhis L'cnihca¢nl lixenP,ion,you should 308 — SHEETROCI<
'hcanne subject m the Worker's Cnmpcnsmion provisions of the Labor Coda you must
O O ronlnwiat county oh oil, ro,inions on anis pe....it Aal I he dramel,coked. 309 — EXTERIOR LATH
Z
F l CONSTRUCTION 1.17NDINO,AGENCY 310 — INTERIOR LATH
1 Imreby al imt that mere is a comuuc,ion leach ag agency for the taloa amr
U.1 of the work for whichhis veratilisissued(See.3O97.Civ.C.) 311 — SCRATCH COAT I v
bender's Nana `
DZ Leader',Address— 313 — ROOF NAIL
U O 1 certify bra I have read this applicalion and state that llic above intoral.aunt is 501 — FINAL ELECTRICAL ENERGY
4ao i- correct.I agree to comply with all city and county ordinances and stale laws relating
O U rot,tmking construction.aadhetchytmm..daerepreWuntives(It lhis cltytoenter nMn 502 — FINAL PLUMBING ENERGY
y the aM t d pct pen Iinspect if rryL (W, g n x04 Ierronly and keep h
Is,hecty'If Cipro Dag amt (�� 503 — FINAL MECHANICAL ENERGY
✓� rant Idy. ,:.c t I p :us 'I b r any 'y lanusaid L/
U Z Cit q 'r g t g rthi,P t 504 — FTNAL BUILDTNG ENERGY
AI'1 I RS NIR ANU WILL COMPLY WITIIALI NON POEM' lSsl1C by: - Date
S )Nc 11--k� a-
SIZES-
sgaa, r� Pit IL °Contractor" line Re-roofs 506 — BIAS TEST
HAZAR)OUS MATPR1ALS DISCLOSURE
Wld,ea,licaa,cr rima hDdding¢eupas,,,one uCi haDme ha,ardars hnateral Type of Roof507 — FINAL PLUMBING
a del n by the Cupertino Municipal Code.Chapter 9.12,and the Ilcahh and Safety _
c dr.. vtion 25532(n,a 508 — FTNAL MECHANICAL
uric El No All roofs shaAbejinspeylgllp-L)r%pgotxifing material being installed.
Will the applicant or future had,ing ocer,ant use equganent or devices which If a roof is imitfk{ d wit l 1 4t o a n'- ection, I agree to remove
h,ardour air conta...iwms un defined by the Bay Arca Air Quality Munugcntnn h A 1'1 �J lst��[ t��_y 4 J_�sl t P a g
- all new mateI�l1s for in{pe tt�pq. p�t,Gahi gntjIs apd�and will comply with
El Yes 0 N all non-poinCsdu�fce re hatitS�4- G u &
I havc read the hazaaluols s arainiarequircnmms under Chapter 6.95 of,he
California l health&Sul'ey Gds Seen is"5505.15533 and 25534.1 unJcremnJ,ha,
if a had li g does an currently havc a It that it is ny responsibility to notify the
o upmn .1 11 re
t it I which oma he mot Wioi m i..wmma of a Ccniliane'Ifwhich Ton he over pries,n i.vwmme of a Ccnilirme of
D^' 1 Signature of Applicant Date
vv �,�-gen t �! rate
All roof coverings to be Class ` B" or better
OFFICE
L _J 62'2
17'9 32'2 4'10 7'5
515 7'37'2 5'2 5'3 2'
f 7
68310 68310 3040 6069 3040
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3268 e
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r 310\` evator . �.
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co CO
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f<1 J — ry I M
- - LIVING AREA
..53 sq ft
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Ve 2668
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(D CO N 1i �`'1 BATH °O
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�} "11 '10 x 7'9
N
(7 41 v I r - Li -
5568 2130
7'3 5'5 L 4'4 ~ - 812
4'2 12'8 I 9'11 12'6 I 11'
50'3
LIVING AREA
1321 sq ft � � < FcAi,,VK kn
DPNCE Wt'tN�
ORDINPNCE3 _
tN pCCOR
CUPER11N0 CODES pN0 `` �2 b^^G O San
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an
SIGNEDt of P ns z°dat ail tim nd s p k r`1 (RO
jh�s °� eltecatil0° I
V, x , JI
COM
be kept on ke anY o�:�nBes �ssto0 tfofn / — I
OFFICE lawf°i t° Wathout W ;.tt of ?Vim°. y Af ►t (j Q
on same Daft„ CdY and sPeccadoh%n ' f" 3 1 �— � U —v� 1
the b°pd1nB of , Dia° it of to .
Ito Okmpm%3HP�L NOS be hV aton omsnl�w,H 9
fo3al
vo
Qgman°e °f State
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