00120005 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDI NO AUIIgE'S;,,._ - PERMH NO
Ali.OAS SCENIC CL CAROLINE IDA 001.20005
OWNER'S NAME..' APPLICATIONS IID T?
• CAROL INE Mn 1, /2000
IONEI SANITARY NO. CON'I'ROI,NO.
0 a Z ARCHITIiCI'/ISINGINGER: BUILDING PERMIT INFO
O BLDG ELECT PLUMB MI7CH
F R al I_J I_1 =1
zz ` Ihmebyoftinn mat Iran licensee arae nrovi.....ofc DN Job Description
LICENSED CONTRACTOR'S DECLARAI
O _w Chapter Y(annmm�cing
with Section of Division 3 ofthe Business and Pmre..iom Ccals.and my license
i,in full force and effect. CHANGE INTERIOR DOORWAY_
d z d Licca c Class Lie.R
% TomCI truant
W S a y ARCHI IEC'I"S DLCLARAHON /
C v.
0, 1 under land my plan,shall be used m puhiic record,
Vi
u ii:p O Licensed I'ndcsionnl
�xf OWNER-BUILDER DECLARATION
e W 1 hereby affirm that I not exempt Than rhe Counselor License Law for the /
C z,��, billowing mi....n.rSenloo 7131.5.Bmineaa and V...m,siona Dae:Any clry rar eau oy
F C which r..Pdres a Death m.... cL mmr.Ilnlmnn,dcmohnh.m m,:dr any.venae
ae PH in it,i,wnnce.al.n myuim,thoopplicunl for such pmniun life a signed statement V ' lip
than he is licenced pm,munatne pm,i,ion.afore Comaemr..LicenM Law(Chapter 9 Sy. Ft. Floor Area f6vu
teommencing with Section 90tH))of Division 3 of the Business one Pmrmxion.Code) V
or that he is exempt therefrom and the basis for the alleged exmnption.Any violation
of Seelion 7031.5 by:my appllewn for a permit s.hjem rhe applicant to a civil penalty
arms i...redimFive hmonmddollars($50o). APN Number Occupa(wrype
❑1.asowncrarlhC r .orm, loeeswlthwaesastheirxaleenln liar. 35707010. 00
Oil b y my Y 6 pens:,
will Business
me work,and me nuacture is not intended e e feredLaw for.me apply
to 4.
an
owner of and property saes:me Com Chemo uacn.e Law dr<,not apply t an Required Inspections
mhhis'o wasbum,mImprovesorsucn,and wonentsamsuch work nr 101 — FOUNDATION
o!mrongn his own howmel,t Provided Clint such ilnpnwcm sold wi nal mendedyea
,ronre mr.me 1L bnwmer,the h,h have
oro'ImPrcwcmcnl..cam within ane rc+lr or 102 — PIERS
"
imPplcllon,mepo eer 'sear will baa Ine roman or prrdans unl,t he not nnrdd m
n, rpurpoFeor,mc.). 103 _ UFER
owner of the prota".am exclusively contracting with licensed ca'it—or.m 104 REBAR
Lconstruct the project(See..7094.Business and Pmfewiom Co,c:)The Common,
iomo,Law does not apply room ox'ner of poo,my who bred,or improves dnareon. 105_ — ANCHOR BOLTS
lot u,nlmcat rnr such,roi3O, .iib a eon,a,aa,) lieenscd punona m lbo
Coano-aclors l.laca.el.w, 106 — SEWER R WATER
❑lam in der 'ce. .n.9 rc na mix rex>o" 202 — UNDERFLOOR PLUMBING
ow^° _ °" �°�•�l-�,ZO"�� -�03 — UNDERFLOOR MECHANICAL
li S C<,IMPENSAI ON E6 RAI ION r—
Ilmelymrr,rl amler Pnadtyofpcjay oncorme louowangdr:ewrni1, 204" — UNDERFLOOR FRAME
I base and will maintain a Cenehmle of Convert ,,sch:merm rnr Workef's 205 — UNDERFLOOR INSULATION
mnpernmPon, a, provided for ray Sworn 3701) of he Labor code. for the 301 — ROUGH PLUMBING
performance of me work for which this pemtit is i,rod.
❑1hilveumlwill mamminWmkcr'.Connpmsa1ionlnsunmcemrenailedbySection
3d2 — TUB & OR SHOWER
370K)of the L^hor Code,for me nrHornr oos,or oro work for which this lrea,m is 303 — ROUGH MECHANICAL
issued.My Workers Compensul ion Imurame carder and Policy nunder are:
304 — ROUGH ELECTRICAL
carrier: Policy Na,
CERTIFICAHON OP FXEMP`GON FROM WORKERS' 305 — FRAME
COMPENSATION INSURANCE - " '
306 - HGl.nownls
rrbHsection need oat be eomPlaaa if me 1,crnnn i,sur r.no hundred mnllnw
a1BBn,nm,.) 307 — INSULRTION
I emir,rex,mme perfmmanee of he w ork res which his .it i,i...ed.1 308 — SHEETROCK
shall not emptily any pen n n any manner so at a become subject to the Workers
Compen,mion law.of Cnllrnmlo.Dole°° 309 — EXTERIOR LATH
Applicant
NOT ICEIH)APPIACAN 1:11,goer making del,Cenmcmc or exce"im,.v."Idomd 110 — INTERIOR LATH
become a.hjc,l ,,me worker.Compemala,provi.mmof oro[.abut nae you now, "'11 — SCRATCH CORY
O Q fmhwim comply with such provisions or this peratir shat]be deaned evoked. 311
F ^ CONST RUCTION LENDING AGENCY 313 — ROOF NAIL
CC 7I berchy^Kinn that there is a cnnamclioo lending agency Iia the performance -
,rlheworklor suchIti....o...oI,smcd(See3097,G,,C.( 501 —
FINAL ELECTRICAL ENERGY
r',
I.cmlc111 502 — FINAL P[_UMBINB ENERGY
Under',Add...
U OI certify that I have mad this application and state that the abase information is 503 — FINAL MECHANICAL ENERGY
❑. F cancel 1 once ,,comply with all city and couny Industries and state rows He ari^g 5d4 — FINAL BUILDING ENERGY
O V u building comaumion.and hereby curhorim mism,ntmives of this city v,Snler upon
p, W meShovesmcmfoordproperykoro,,,,llmtpurpus`, �Fwy:
505 — FINAL ELECTRICAL_
try y (We)vgrccmmve,indannffy and kccp han^Ice.Ibc Ci ly ill'Cu[xn In^agafml
rn IiabiliJe,,judgmem.,cost,and caper,,which in.,in any way acerae aieiml said
505 — GAS l'F_S-f
V L Cov in come,goccml digranting of this liens.
APPI, ANT UNDERS'ANDS ANOW LCOMPLY WITHAL[.NON-POINT 507 — FINAL PLUMBING DateSOIA a, :GI1L TI /, / 1�,-,.a —
Si t A IiauroFrm 000r _ I/1'I IIuNcLV lL - IFIRE c \ _
e Pp Re-roofs
IIA%ARINOUSMATERIALS DISCLOSURE 909 — FINAL_ GRADE
Will the rill or lumre budding occu(am sure rar handle b.nism mmneal Type of Root' `
mdcrnalby0.alma.MitmeipdCode.Chapter 9.12,rudmeHemlband Sa'el, 51.0 — FINAL PLANNING
Cade.Section 25532(x)?
0Y 0N All roofs shall F5elifispectda1*161l to Pili lMoTiiFg WDPIAEbeing installed.
Will theapmica„t ormoneholding occulmntUse agniptnertordeviceswhicb If a roof is installed without first obtaining an inspection. [.agree to remove
c m,ba'eadou,air umnam.mam,as dehnc,I hr Inc Boy Arco Air Quality Managmnaml
m
,iser, all new materials for inspection. Applicant understands and will comply with
OYes 0N all non-point source regulations.
I have maul the hat,odous materials requirements under Chapter 0.95 of the
Caliber Icuhh ffiSafely C'odc,Sermons 21MM 25533 and 25534.f uoro,lund It,.,
[fine hui ldin"b"nolcurm, yhave aemool,lbniti—ey m,salsoillly to soli l y the
ccuPxn be requirement which amt be,net prior m mtaime rar a Cenificufe of
Signature of Applicant Date
0 oro rr� �d m� U All roof coverings to be Class "B”or better
OFFICE