00050203 F
ITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
DING A DURESS: PERMITNO. "e` Vi��
11108 SUTHERLAND AV
IWNER-S NAM17: APPLICATION SIAM50203
GOODRICH GORDON F AND DI.F_ DRE �A ff�aap1 �prk�p{q�
PHONE: SANITARY NO. 05/30720ZO
ncv ARCHITECT/ENGINEER: BUILDING PERMIT INFO ,
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Z O m LICENSED fart
licensed
ands,S DECI.I,it Cia CSCrlptlOn
Ihereby 011 ,l'tl o . Jud p dC,nptcr)(wnnclise
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ARCllCT S OECLARAI
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fly
�6p LicenacJ Prolcnsional OWNER-HHILDF.R DECLARATION 1/2 BATH, LAUND Yi�FS..ITC . LL BATH MAST
^— 1 hereby affirm that I am eaempt from the caatmm n',Licence,Law forma REMODEL -
t- following roam.(Section 70.31.5.Humus„and Prufeeviunx Cn le:Any city account,
wM1 I P it I t o Iter,improve.denoofiIh. 1 y structure
ue p'o t :. 'I: ,,hea,,[wantf .it fil,asSnedLtate,c,
tiaa he isbavnwpairsuran to flue,to......a Ill c I' t,r,l Law(Lhourr9 Sq. Ft. Floor Area Valuation
b, nu ening with Section 70(Xb or Divisian 3 of the Ifmine,,and prof c..iuro Code)
m that he i,cwmpt,hc.ir...t Bad the basis far the alleged cnetnptlon.Any violmion
of Section 7031.5 by any applicant for a pemlit subjects the applicant to a civil penalty
of not more than five halved dollars(6500). APN Number Occupancy TyA-000
01.as owner of the proNA,,or my employees vimwase,,no their sale compcnsaaon.
will do the work,and the amcture is no,intended or ortemd for sale(Sec.701
Haines,,and Prolcssioa,C1We:One Contractor.Lical,e Low does net apply to an 3561.7060. 0LRequired Inspections
w nes of pn"ri,Who build,tar impnwcs thereon,tonal wba don rich work hi tn all
n through brs own en,Pl(ycu,,Pn rded that such intpm intended o,
otanad rot sale.11,ho"'e,IIIc nuJdiag a repro sol s Mold w thin o r ycu of
weve
,,aupfal far tnc owe or'ale.) will novo the.AUNen of proving thw he did nm Haim nr
tnpnrvc for PUHrow nf,alc.b
El 1.as owner of the ifropemy.am exclusively contracting with licensed contractors to 101 — FOUNDATION
Lmmact the p iect(Sea.7(114.Nosiness and Professions Code:)11,Coutmern",
icense Law doe,not apply to an owner of property who bails,or improve,therron. 102 — PIERS
and who omat for such projects with a commnmlV licensed pursuant III the
Contractors License Lme
O I:IDI exempt under Sec. .11&P C for this reason 103 — UFER
Dwnct Dan: 1.0T4 — REBAR
WORKER'S COMPENSATION DECLARATION 105 — ANCHOR BOLTS
'SJ,
Ihanchyoil!ra,aadmhraallya1 arjuryaceofherouowingdeal arahon.: 1.06 — SEWER & WATER
❑ 1 have and will maintain a Celnhcatc of Consent to,clf.m,om for worker,, 2202 UNDERFLOOR PLUMBING
C..u,smmion. a, provided for by Sation 370 or the L,h— Cade, for the
peHormance oftk work lin which this permit is issued 203 — UNDERFLOOR MECHANICAL
I have and will maintain Worker's Compcmatian Insurance.as rapried by Section 204 — UNDERFLOOR FRAME
J7bo of the Labor Code.for the performance of the work for which,his permit is
issued.my Workers Contpernation Insurance varier:rad Policy retainer me: 205 — UNDERFLOOR INSULATION
Ca.....1 rtl�fUM� rahayNrHoO.: 61'ww —UU 301 — ROUGH PLUMBING
CEHI'119C COMPENN TIIONIN.SURANCE(11tKEItS' 302 — TUB & OR SHOWER
('Ibis werion need not be completed if the grout is lin one hundred dollars 303 — ROUGH MECHANICAL
(,,labile,,.) 304 — ROUGH ELECTRICAL
1 eerily that' .a c perfnnwna of the xn,k Ins which thin permit is isued.I
.man not emplo y an in any Ir:I I. a Io hr oin Z hjcar m t e warkis 305 — FRAME-
Applpen,aho w;rE.daomm.D = 306 — HOLDOWNS
Applicant
rvoucHTo .I.nNT:lLarmtt mgt �, e thettte :. tptmn.yau,noum 307 — INSULATION
nventncathjM at the worker',Ca emanon pray tin of the Labor code.you nota v
rormwlat lnmfly wif[,.aeh moi,ion.a.this prrodi,m:,ll he d,.I,ed luvoked. 308 — SHEETROCK
CON."RUCTION LENDING AGENCY 309 — EXTERIOR LATH
> 1 hereby allinan that timre is a construction lending agency for the peHorm usee
of the work for whichmi,permit is i...ed(See.3197.Civ.C.) 310 — INTERIOR LATH
LeadeCs Name
LD Z I<nder's Address
311 — SCRATCH COAT
1 eerily tent 1 have read this application and state thin the above information is 31.3 — ROOF NAIL
correct.I agree m comply with till city and county nrdin:mcu and state laws rebating
O v nobouldin,Ina,,ton,ion.:Iwbeehyaathorinrepreentatives of this any to enterala'e 501 — FINAL ELECTRICAL ENERGY
the ans, a,(,ter onv-mentiot""redoa pipna a.
W (We)agree tnaave.imletonilyaadkeep Isatme„timChyafCupertino agains' 502 — FINAL PLUMBING ENERGY
[n liabili,ie%.judgmm...Gas¢and expenses which may in any way mance again,,,sed
U Z City in come,arive of hegounty, it'his m,it. 503 — FINAL MECHANICAL ENERGY
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: B
SOURCE REGULATIONS. y'
Signamm nfApplicanVCnmmctn, Dmc Re-roofs 505 — FINAL ELECTRICAL
IIA/.ARDOUS MATERIALS DISCLOSURE
Will the applicamor fate.building ma...at acre or handle ho,ohastnorrial Type of Rodit06 — GAS TEST
a,defined by the Cnpenino Municipal CII Chapter 4)12.and the Health and Safety
code Seam.,25532(x)? 507 — FINAL PLUMBING
Yr, All roofs she.{ Ipyp .tg� Icx �t�B� 41,w aerial being installed.
Will the applicanttar fmom building rucapat'use e9dtNaetnor device,which If a roof is ig ed wltFhY� y'.tit 1111jj[]�'. .y�Q{,�yeg4alrt1n1tt},IY1nspection, I agree to remove
cmiticl? ,ain'onteminumtt a,derined yy the Hay Arco tis Quality Management `IS I IV lIVU
D"itho all new mat�[[rT for i R r el
stands and will comply with
oYea all non-poir7Y, ce real
1 hoar real thr ha,.than,material,ar,mmat miler Chapter 6.95 of the 514 — FINAL PUBLIC WORKS
Cali. he Sdmy Coate.Sections 25505,25533 and 25534.l understand the
it wilding non not currently h' ant.th:n it i.,Ins relams.Nmtyounanythe
ccaNr nr a rnptimmm�,s x' en m be met prior la issuance al a mlicate or
°oa°I""' c Signature of Applicant Date
Owns"',naborned ager 3U All roof coverings to be Class "B" or better
OFFICE