02050162 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BILI�Wr3TE ftEVENS CREEK BLVD PERMIT NO. 02050162
`9
c9T R LA JOIE "CP5"` nrltn
PHONE: SANITARY NO. CONTROL NO,
MaiO ARCHITECVENGINEER: _ BUILDING PERMIT INFO
E U BLDG ELECT PLUMB MECH
ren a J L--1
S y Z LICENSED CONTRACTOR'S DECLARATION Job DesC ptlon
;Z-o 1hereby nfBnnthe,In.lit,m,,dunderpmvisi.M.fChapter 9(commencing INSTALL 2 SINKS
rut with Section 7000).(Division 3 of the Business and Professions Code.and my beenee
x f is in full force and effect. -
O�U License Class Lic.
Ume tar t
1 a O� ARCHITECTS DECLARATION
3 1 undemm�d my plans shall he used ed asos p public records
7 z o o Licensed Professional
K o OWNER-BUILDER DECLARATION
,olv, 1 hereby affirm that 1 am exempt farm the Convector's License Law for the
t?< following reason.(Semon 7031.5,Business and Professions Code:Any city or county
Fm D which requires a permit to construct,alter,improve,demolish,or repair any structure
�r3$ prior in its issuance,also requires the spli am for such permit to file a signed statement — ------ - - -- --
theth5islicensedpdau6di tdlheprovtsi.nsofNeConuectorsLicenxLaw(Chapter9 Allia-, a"i a- Valuation
od
(commencing with Segiont]000).(Division3of the BusinessaM Prolusions Ce) '
or than fie is exempt theiefrom'nnd the basis for the allegad exemption.Any violation
of Section 7031.5 by any applicant for a permit subjects the applicant to o civil penalty-
'orom more than five hundred dollars($500). lUiAPN ti :• Occupancy Type
El 1,as Our of the pmpeny,u my employee with wenm
ages as their sole c.mption, 102 - PIERS
'will'do the work.-and the structure is not intended or offered for sale(See.7W, Ur zit
-
tBhsimis and Professions CWc:The Contractor's License Low does not apply to an Required Inspections '
owner of properly Who builds or improves thereon,and who does such work himself 104 - REBAR
r two h his own employees.Provided that such improvements art not intended or -.10 5" '_- ANCHOR'_BOLTS _
woos _.. __.. __.. ... .. . ...... woos. ... _..
Reree or sale 1L n lde the building a Improvement n sold within one year or
eomove for Pm oMmcnf,h,.).will have the burden of Droving that he did nes builds 106 - SEWER & WATER
improve for puryou of sale J.
..sown. peso__-. .. .twos .. .. .. _. .- .__ _ _PLUMBING- __ _ __.._..Z. .._...
01, - props y.vmcsclusively g 202 --- UNDERFLOOR .PLUMBIN -
owner of n contracting with dr:) o C.otmtsto ..
coniwathe project(Site
appl 1. Businessand aywhobrodeoThe mth,cors 203 - UNDERFLOOR MECHANICAL r, ,
r
License wh Law dasnot apply mmjccts ah properly whobuildcein d[ provesthto tho 204 - UNDERFLOOR-,FRAME-_-_
and rvemos kens for.suchProjects.with a.commctagsl licenced[purtuant to the .__.___. _ _....-_. .. _.._.__..._.-_.__. ._.. . .
col .asraucxnse S 205 - UNDERFLOOR',INSULATION
' ❑I em cxe pt send' Sec � � '' '�,B'&P C fo tit¢r ason
�� 301 — ROUGH PLUMBING W CE COMP10N DECLARATION"'-"*— 302 - TUB k OR SHOWER
Iherebyafrte,under penaltyofperjuryone of,thet°nowiagdeclamtions: 303 - ROUGH MECHANICAL
❑ 1 have and will inaintam a Certificate of Consent to seleinsura for Workers 304 - ROUGH. ELECTRICAL
40 1 Comperes"...-a.-provided for by Section 3700 of the Labor Code, for the 305 — FRAME
perfomlanaofineworkforwhichtnnper,nirsissued.. 306 — HOLDOWNS
❑1 have and'tibi mammos Worker's Cumpensatimi Insurance.as required by Section 307 - INSULATION
37M of ma
the Labor Code:for the performance of the work for which this pewit is
r: issued.My Worker's Compensation Insurance'carrier and Policy number arc: ,
_ 308 - SHEETROCK
calm;' a=: „q sat k„rdmicyNd.: t 309' r'_'`EXTERIOR ,LATH:, nits; i:r.
" H'i"',CERTIFICATION.OF EXEMPTION FROM WORKERS' - ' •` - s`
COMPENSATION INSURANCE `°' - _
twos _... _._.._.__310_. -..IN.T&RIOR__LATH.. _ .__. _. .__.
❑Tis section need not be completed if the permit is for one hundred dollars 311t SCRATCH COAT
.s
aloo3.rlea )' " _woos 313 - ROOF NAIL _
1 nlfythaunthe perfomtance at the work'for which nils facing is Issued.i 501 — FINAL ELECTRICAL ;ENERGY
ih 11 fi t employ nary person m anner s o c b) t t the Workeri
compmmon sof Dula, ��b _ 502 - FINAL PLUMBING ENERGY
-Apel
"None ANT If,after aqn flus Ce to ate of Ex pie yoy ahimildst 503 FINAL MECHANICAL. ENERGY
become atomthsuchr'sCoionsortmnprovmonso(mdamned awaked.
504 - FINAL BUILDING ENERGY
� O fonhwith comply such provisions or this permit shall be deemed rtvokM. _
a,' 505 ' '"FINAL"ELECTRICAL
'CONSTRUCTION'LENDING AGENCY
506 — GAS TEST
I hereby alTrm thenherc I-a conswctl n knd n ag ry fo the perfowanax t.
W-Gonh wo km wmtnm pe a aiya(stt 3(ro7 �iv.c) _ -507 — FINAL PLUMBING - - - --
Lenders Name. . : .,:..-, � .sows ., .� ,.. .:
�'. Lewers Address':.._
Z -
U, 508 FINAL MECHANICAL '
1 certify that I have read this application and state that above information is 509 - FINAL GRADE
rz"(~ emote I agree art comply with all city and c...ty,ordamc,es and state laws relating
O...0 to build'0 co vucu n and hereby sudimize rep entatives ofthis city t enter upon 510 — FINAL PLANNING
the bovcm ue.tdProprytolyandknpharmlv._ 514 - FINAL PUBLIC WORKS
(We)agmetdsa a mdcmnify.nd ke i harmy in the way Bram,all inst and
U W Cliabilities,tyconsequence
cons d expenses Mich may in any way me egaina mid .§
6,7"Z City m canseq entt obit granting of til pew t _
APPLICANTAPPLICANTUNDERSTASNDS AND WILL CO MPLYWITIi%LNC�IPO T-r Issued by: DateV RE
"r\�SAlpl
SOnatuu'off/Afr'PIVJpNMILLmtanpkpC/1/}{{omrcno X177--�Ift;llD--etcYT[` JZ Re-roofs
" HAZARDOUS MATERIALS DISCLOSURE ' •
`,.NJIiAc applicam°r,fulmo building acupam stole or handle Sniandous material Type of Roof.
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety - -
Code Section 255320al /° - n ' •a s : r p S t.
[7 Yes- '14 N _ t t=; All roofs shall be inspected prior to any_roofing-material being.installed. .,___
Wilt the applicant or future minding occupant use equipment or devices which If a roof is installed'without first obtaining an inspection;I agree to remove
amt haenNous air contaminants defined by the Bay Area Air Quality Mehagdment
District? .� / all new materials for inspection. Applicant understands and will comply with.,
Dugs ,I 1, - . all non-point'source regulations' .
I9' I have read the hi seal materials rtquimments mder'Chapm,6.95 of the
Celifomii Health&Safety Code,Sections 25505.25533 and 25534,1 understand that _
ifth'e building does not currently have a Moral,tied it is my ots,nsibility to notify the --
o2cdpent of me requirements whi must be met Prior to ivuance of a Cervi sate of
"" yu ;t7l� 240Z-
m Signature of Applicant Date _
o .risen o at"[ D to All roof coverings to be Class "B"or better '
OFFICE