00080230 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
HUI LDINC ADDRESS: PERMIT NO.
rIRNR GRESK PI—YO PEYGONWC 0140POR20
OWNER'SNAME:_ _ APPLICATIONSUB DNIL
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iPHONE: � `• SANITARY NtI. � I C[) 'I ItO1,N4
z z ARCUITECDENGINEIBL iR -BUILDING PERMIT INFO
O 13L I LE PLUMB 4t 1 LC I
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y
N P' LICENSED CON'FRACIOR S ULCLARAIION
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is I hercbv nflinn,nnt 1 a.,,heen,ed n„eery pr,,;.den,nrcnnrvcr v ae,,,menaing Job Description
°_C° with Seninn]IIrX)1ol Divizioniel me❑urine<.and lmdcuion,C,Nc.anA mYlicenw
a is In full ILrcrmd ctfict.
a I:iren,e Cts” Lic.N
nate
Ar
INTFRIOR REMODEL
ARCHIlECT'SDECLBATIUN0, I nndccaanAmy plan,,hallheuwAa%public
.ccoN,
ay
a o o Lieenvrl rrdt„ional
OWNER m BUILexempt
n the Contractor's
>.ail m I hereby acorn mm I am exon...limn,.M1e ..IsC Any 1 Lu,v for the
G, oxingm ,.Iseednn axI5,a. he,nmpri'mrn,oro GNI',MyGing ormanly
— o rio,1 nyu,v.a Iennii real
ev rue,alto,improve,de .it ,or repair any,.memrc
u6°"13 6 ..Doth . c Ixorcy to ..plica tf nprrmin,is L dsm,emem
mann 1 d.. t t n p n, nn c tor,L en � (Chapter Y Sq. FL Floor Area V at�gt
conuavalling 'd Section 700.11 rD ',i, .. F I be It 'acs JI lc,ior,CnJcl
or that he is 31.5 b zany applicant
and the apers los t p coo the uxcmpnioo Any l cardly
all
of Section a th n iv any dyed doll for a permit.mhJca..hc applicant.o a civil penally
,.r not more mon rive hundred dollars(S500. APN Number ipancy= ”
0I,.,owner of me Prupctly,nr city anployee,with wage.,u,III,,, W,ann',ca'; an,
will do.he work,:ted the,.m.urc is nm amended or offered fir sale(Sec.7ta.
Ruane,and Pmressimss Code: Me Cnnlwlor's License Law Arcs non appy'm an 1 "• eyuired Inspections
rep properly Who milk or improves thereon,and who deco such work him,ell
...through his own cmploycc,.provWnl that such impnivcnten.,arc no,intended or
offered for sale.If,however,the Wilding or inipnwement is sold within one year or 101 — FOUNDATION
completion,the owner-builder will have the buNen of proving than he did no.build m
i prove for pnrptoe err waded. 102 — PIERS
Cl L as owner of ate pmpcny.nor exclusively contracting with licensed coim:tcmr,to 1.03 — UFER
em.micat hep deet(See.744 Business and Professions Code)The Cnmracmr a
License Law does not apply to an owner of property who builds or improve,thereon, 104 — REBAR
cane who parva,,, rte each px,ocl,watt a cn,nruuwr(s)lica„cJ purwan,to,hc
emushe"Lfcen,o law. 105 — ANCHOR BOLTS
❑I am exempt under See. .H k P C for the reason 106 — SEWER R WATER
N
202 — UNDERFLOOR PLUMBING
WORKER'S CUMPENsAflON Uf:CLAH,\l'I(lN �-
Ihereby chiral under Penalty ofperjury one othe following declarations: 203 — UNDERFLOOR MECHANICAI_
0 I have mm will ;...imam a Cemhealo oI Co,c t n,,11-huurc lar Worker', 204 — UNDERFLOOR FRAME
Compensation. a, provided for by Section 37110 or tete Lanor Code. lar the 205 — UNDERFLOOR, INSULATION
performance of the walk fur mmich this permit is issued.
0l have mad ,It iou'llmn W..ker,contlw,oano ln,.ame,n,"'...sial by Sao...1 301 — ROUGH PLUMBING
3700 of the Laim,Coale,rte he pcm,nnenee of the week or which thi,pemm i, 302 — TUB R 0 R SHOWER
„ped.My W'od.cr',Compensation Insurance carrier and Policy number arc:
CE nMG!/C'4.V 4 Policy Nn.:to C2�1,'}'IoS�ItD 303 — ROUGH MECHANICAL
CERNgcAI ION OP EXES"I'rION FROM WORKERS' 304 — ROUGH EI_F_C I R 7 CAL.
COMPENSATION INSURANCE
nw„eraon mal nm he it tw permi,i,fn.erne headrcd dollar, 305 — FRAME
fxllNHmle,�,.)
305 — HOLDOIIJIIS
I edify mat in he pedoranowc err be w...I,rill which oris..snob i,ia,ued.I 307 — INSULATION
..hull no,employ nay peso.io any am ler n,a,m loco hie. ,,me Wo6wo,
cempenudi IL nti: ;m ! —oil 308 — SHEETROCK
A,I earn
NOTICCIndPI'=,AN .If.aner mmkmg ma<eenieeme of Exemption.you should 309 — EXTERIOR LATH
herome,object m the worker,Cuntpcaxmien pmvi,imn of the Limo.C,Mc,von mast
O ZO Immwhhcomply whhsuch pnvmionxmmi,Peru,,(,hall bede.nela,voked. 310 — INTERIOR LATH
FCONSTHUCIIONLENDINGAGENCY 31. 1 — SCRATCH COAT
7. > 1 nklo,amus,inat mere I,a eoaumebocr loading agency roe he ledurmna” 313 — ROOF NAIL
nrthc wore Ibr whirl,this pcnnil x i„,d(Sc,.30x)7.civ.C.)
Name° i<'�d�r Addle„ 501. — FINAL ELECTRICAL ENERGY
uO 1-nifythan n, and iIii,a,,,h,;mo.land snal thxttnuahnvendarm,li„n is 502 — FINAL PLUMBING ENERGY
❑, p. correct.I agree it,comply with all city and county ordinaoee.:ted,tate laws telarns 503 — FINAL MECHAN I NERDY
O (_) .o building .truer d heby H p .. sof this t t ¢r upon
>, m meats `cit Iproperty f inspection ptp, . 504 — FINAL BUILDIh _ ,GY
A. Wo ag 1 Ty I keep l' less'h cilli fcnn again',
m
liabilities,idg L . f oto c n r rx y ...... ,aill — FIh1AL ELECTRIC
V z City in consequence or the Wr ng or m„pc.m,. � `/
r SOUHICL ND WILL COMPLY WITH ALL NON-POINT Issued by:�Yt�1 G_ !`I �-UC4i Date —Ca)
r/—vii —op _
Signature of nppliran ow"I'll Date Re-roofs
uA%ARDOUS MATERIALS DISCLOSURE 508 — FINAL_ MECHANICAL
Will she applicam err Duma Molning„xupart store e.handle na.,,meo,mmedal Type of Roof
n,donml by the Cupennn Municipal Code.Chapel 9.12.nod the llodmend smt'y 509 — FINAL GRADE
Code.Section 25532(a)! '
0Yo` All roofs shalf1t0ispecEd bIcidr tel Inyl dIATIg6haterial being installed.
Wil ineuppliead e, aurchuidingoa.u,c lose equcon o.eueire,wlacl, If a roof is installed with[T41Ifj(sIs)h ttilTlhlg irlgp��tp(i�, l agree to remove
coli.hueaniom air cnnlantinan.,a.,dc.in by doe llny Arca Air Quality Manage car
Didricr. all new materials for inspection. Applicant understands and will comply with
0Yo` all non-point so s.
1 have repel the Sa Safety
Code,materials rcquimncns under Chapter 6.95 0l the
d the mil Health k Safety Cede.Section 255(15,255,3 and 255X.1 undersmnfycited
the
I(nhcM,ilAing J,e,nntcuremlyhave'a Nnam,mat it i,my rmrymsiM1ilhy m,notifythe //.•.O�
calx.,nl of 1=1111h rcynrc which luaut be mo prier Ira i„um¢'c err n Cenif icatc of
°acoryincy _ _ Signature of Applicant Dale
o 31
Ownu onmlhn
All roof coverings to be Class"B”or better
Date
OFFICE