01040107CITY OF CUPERTINO
CONTRACTOR INFORMATION:
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERdH r No.
f
OWNER'S NAME.
APPLICATION SUIt DATE
/ 11
PHONE:
-
SANITARY NO, CONI ROL NO,
ARCED I EC'1'71INGINEER:
BUILDING FROM'I'INFO
BLDG FLECI' PLUMB MECH
s
1=1 1-1 I-1 rJ
LICEJI SED CONTRACT ORS DECLARATION
lob Description
1 Mmby affirm Thal 1 am licensed under provisions of Chapter (commencing
with Section 7g)fl1 al' Divi,inm i of the liminms and Profe„ions Cld' 'Ind my Iivenv'e
i.in tall hc,e an,�dlecl. / �G % 6 7�
ice`n.a e_m.� C Lie. x
REMODEL
FIRE PLACE,
_
_
AIIculTECT's i)FCCARAT[ON
ADD 38
SO. FT. ADDITION.
I under,mnd Ivy plans shall be urea as Fuh1w Iveml,
�'
ALED
hPa
cea olrofe,mal
OWNER-BUILDER DECLARATION
I thereby .(brio mal I an ,:venin hose the contactor'. Lie..sec Law Iar nae
u and Prnlission, Code: Any city fir y
Follow I., r :ora (Seeliom 71131.5. Businecoum
J U L G
2 2001
which "ahee a permit to construct, alter, inputs c. demoll,h, or repair any %oucture
pror to is... .I.u reunites the plat cantfor such Mannit to 1 It, . signedstatement
Sq. Ft. Floor At
Valuation
Ilan lie is I evanood1ansucirt n, [lie In III1 x of t ( I Lilcacv I 'lcl,Smer9
tense S., VIE) Di 1.1 the Bu, ire,i p..': Code)
, wilh n at m , , and
rare c
or that he is exempt therefrom and the basis for the alleged exemption. Any violation
B
ILDING
of Section 70331.5 by any applicant for a permit subjects the app(icon( to a civil penalty
olio( mominanFive lmndreldopmn(S5d0).
APN Number
OccuparVy31V18eW0
01, us owner of the properly. o my employee, with wages as their role anmpcnulio.n.
.. 3570908CecL1111§�d
Incti
}o� speons
1L 4
will do the work, and the structure is not intended or offered for sale (Sec. 70,14.
Bus s, and Pn,fa„ien, Code [he Cooka,lor', Limnaa Law disc. nut apply Ie an
ol properly Who build,, mpr es mann, and win does such work binuelf
or through his own employees. provided that such imps ecauen,s M mot intended or
oflered far vale. If, howevct, the building or improvement is sold within one year of
ompled,'„f menwner-huddler will mwc fire larden(it proving that he did mot build or
101 —
FOUNDATION
Improve- purposed
102 —
PIERS '
❑ I, a.,mner of the p.,r,, aexewawely corroding width licensed crouse... to
eonnmcl the projcat (See. 7(H4, ILldnes, and Profewo., Cote:) Tine Cumueuals
103 —
UFE R '
License [.aw the, not apply Ia an owner of pt I... build, of in,mov, bet on.
and who comma, for such project, with a comraema,) licensed pursuant to the
104 —
REBAR
Commc ur, License Law.
I7 lain ucnlpt urder Sec. . B ox P Cl or this uv,,,on
105 —
ANCHOR BOLTS
Owner Date
105 —
SEWER & WATER
WORKER'S COMPENSATION DECIARATION
202 —
UNDERFLOOR PLUMBING
Ihereby aumaunder crudity ofpegaryta,ofthe wuowingdeclarations
203 —
UNDERFLOOR MECHANICAL
❑ 1 have and will maintain a Cyil irate of Consent to m•Labon for Worker*,
me bar coat, for the
Cumpcnloas pnrvidal fins bby Ssr,ion 1700 of Labor
nan,
204 —
UNDERFLOOR FRAME
x-rf 1 f the work nor which mix issu«I.
205 —
UNDERFLOOR INSULATION
nl, pen,ado„m,amna.III re.lmiredn>S«ton
0l have and will amain Worker Comped-Li
for to;
301 —
ROUGH -PLUMBING
3700 A the LaMar code, rot me p<mannance of the work which this Isemrit
issued. MyW ' Compem,afi, trance cart er and Policy number arc:
C v�
302 —
TUB R• OR SHOWERca
”' Policy
GCliff1'IInCA'I']ON OF EXEMPTION FROM WORKERS '
303 —
ROUGH MECHANICAL
COMI'ENSAI'ION INSURANCE
304 —
ROUGH ELECTRICAL_
('LTi, ueio I need not be completed if the permit i, lot one hundred dollop
305 —
FRAME
($IF(A of Irs")
1 certify that in the Performance of the work for which this per of i, i„aee, 1
305 —
HOLDOWNS
shall nn, employ any person in any manner m as n, become subject to the Worknri
307 —
INSULATION
compensation I4Iw,,ar c.difrrit Dade
AppicrIII308
—
SHEETROCK
NOTIC, n) APPLICANC II: after making his Cenircale ml lineradi I. om should
become ,ubjecttothe Workers Compen.am,npmwaomofhe"We Code, yen must
309 —
EXTERIOR LATH
forthwith comply with,ach provisions or this permit shell be deemed reeked.
310 —
INTERIOR LATH
CONS9 KUCTR)N LENDING AGENCY
Ihereby mrrnhat here is acmrswceonlending agency for the petrnr once
311 —
SCRATCH COAT
of he work in,, which his permit i. issued (Sri. NAP. Civ. C.)
Lcodvr, Name
313 —
ROOF NAIL_ .
Lelder, Address
501 —
FINAL ELECTRICAL ENERGY
it
I,In fythin lfree read this amIemlonand sloelhtheaboveiafornation
,,I've L 1 agree Io <m....ly with all city and c„liirly mdnnln,v, and m,Im lava cowling
502 —
FINAL PLUMBING ENERGY
to building a,mtuc(ion, and hereby amhoriae n'prnummive., of his city In emer upon
,he amwc-mcndonedProperty nor inspection purposes.
503 —
FINAL MECHANICAL ENERGY
(We) agree io raw. Indemnify ant keep haunt... he city of Cuperimo agai ltd
Iiabilitie,.jo igne"d.. cool, aim e,p.nw, whirl, Inay in any way tirloe:Igoilr,I said
City in cnnm9uence of the of (hl, I
504 —
FINAL BU I Lll I RIG ENERGY
I
punting scroll
APPLICANT UNDERSTA SANDWELL COMPLY WITH ALL NON-FOINI'
ISSUedb 505 '—
y'
FINAL ELECTRIC�te
SOURCHREGII oNv
Re-roofs `
507 —
-
FINAL PLUMBING
simulate If IF Iean n k or Dale
IIAYARIRl11SMAEERIALSDISCLOSURE
Will theappli,con or future Wilding occupant store or handle horribus material
Type of Roof `t718 —
FINAL MECHANICAL_
I, detimed boric Correct Mumlclpal Cote. Chap,ar 9.12, and the Hridth and Safe,y
CWC Saeion ]5532(x)'1
❑Ye, 0N
���p p(�
All roofs shall bei OM&n gIOTI 6inaterial being installed.
p�T y
Will ,he tmpllcnm of inure minding o,,opmt use c,,I inmen, or devices which
'e�i'.tefi
If a roof is installe� AYloult
_ f�•1t
(�II
9AJR1 in PI71g41A 5$CC4'Ion, I agree to remove
eenl
mi, hivaon, air contaminants m ddined by the [lay Area Air Qual dy Mansgm
emit
all new materials fffrlilb;pecti6nIbgWicMWBbdF%staW13Fd(Zvi11
comply with
DYc, 0N
all non-point source regulations.
I have rciW he nurardon, on void, ,eduirmnems ander chapter 6.95 of thv
Caifomia Health k Safety Ede. Section, 25505, 25531 and 25514. 1 °ndenmad In.,
qq
If he building does no, currently have a Icarian. that h is my msEwa%bilidy do nonfy he
/^
/%ZQ ^V(
unpin, of hu re"'one w1(ch rout be Incl prior to Issmmce of a Ccnilicam nl
—
i
edurn
�9�
Signature of Applicant
Date
— /—�
All roof coverings to be Class "B” or better
O .n ami a, I.gem Data
OFFICE