01110093 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BETb`§�VTYCAMORE DR. PERMIT NO ty� 01110093
O`1,215'V`STOTTRUP "p] �Aj��`/ L b�1
/ PHONE: SANITARY NO. CONTROL NO.
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e sZ ARCHITEC(ENGINEER: BUILDING PERMIT INFO
O C BLDG ELECT PLUMB MECH
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h= LICENSED CONTRACTOR'S DECLARATION
1 berm nitro a,at I am licensed"neer Tena t9 anmmmcin ob Description
a provish,ma Per g LANDSCAPE ARBOFI(.
;mF with Section 7000)of Division 3O the Business and Professions Cade.and my license
is in full Im<e v cit,
i z < Liccnu Clxa�. Li<.a
'O a V Dmc ECA
S D !
7 3 y v ARCHITECT'S DECLARATION
uo d I onderswnd my plans shall M1c used as pante rcn,rds
; l Ig
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I m o O Licensed Pn,fe.siooul
X u
'Y OWNER BUILDER DECLARATION
m I masa affirm rnm I tin exempt from the Confusion's License Law for the $29000
ce?< following reason(Section t ]o3L5.Business me Professions Code:Any city or county
'cam,F❑ which is r n, 1, construct, h improve,demolish,t repair 5 t nese -
a 3= Peron , ml also d 1 in applicant for such Permito File signedstatement
minfo th n m p ,mm 3 o he m orx,, Lo ons(ClCor) .3 9e?$'6 BIZ&ABla t . , , Valuation
Immmhe is e :ith t mon]OWI of Division 3 the
lJus nes.and ion,Anon.Code) f'
or thatheis nem pt therefrom and the hasps for rbc alleged fitcment In Any violation
of Section 7031.5 6y anyvpplicam faro permit subjcds me uppli<unno
of no,mart than Ove hundred dollars(5500). Pal A L E Q 1%PN iii lRVDATION Occupancy Type
❑1,as owner of property."r my emplanes wpm wages as their sole compensation. 10 2 - PIERS
will do the work.end the structure is not intended or offered for still,(See q —
Business and Professions Code:The Conuanor's Liceme Law riots not app' t LO Required Inspections
owner r of propcdy Who nadax or impmses thereon,and who does such work himself 0 4 - REBAR
orr mmugn his own employees.provided huddctl that such improvements is Old
are no,intended or
-nrrl,rte for sale.u.however:me nwlam - t is.ale within me r - 105-- ANCHOR- -BOLTS
geburden cmen U LDING . . , ..
improveion.meowner-builder rill havc,he harden of proving thel he Jid nosh 106 - SEWER & WATER
improve for purpme of sated.
202 — UNDERFLOOR PLUMBING — ....__ _ ... _-...
C I,as owner of the progeny,am exclusively contracting with licensed contractors to t
construct the proj«t(Sec.loan,easiness and Professions Code)The Contractor s 203 — UNDERFLOOR MECHANICAL .
License Law does not apply to an owner or propenr who builds or improves thereon,
and who.c.mm Ix for such prnjee,, ,in..eomractna.)licensed.....aam l"the 204 . - UNDERFLOOR. FRAME... -_
Conracoes license Law. 205 — UNDERFLOOR INSULATION
❑1 am exempt under Sec. _ ,11&P C fnr this rea.snn
Owner I nate 301 - ROUGH PLUMBING
WORKER'S COMPENSATION DECIARATION 302 — TUB & OR SHOWER
I hereby affirm under Penalty of perjury one of following aeclarsomma: 303 - ROUGH MECHANICAL
li
01 have and will maintain a Certificate or Consent io ser-imme for Worker's 3 04 = ROUGH ELECTRICAL
C"mpp,mitm, as providl,a for by section Jnro of the Labor Code. for he 305 FRAME
performance of life work for which this permit is issued,
❑I have and will maintain Wooer's Comp<nsalt"n Irmranc..'o regioned by Section 306 - HOLDOWNS
37W Of the Labor Code,for the p nforzmnce of the work for which This permit is 307 — INSULATION
issued.M)Workers Copensation lnsurm¢carz comer and Policy number are 308 — SHEETROCK-.. -
/ . ... ..:.,v. :.. ..,
Canerf*7Y-74(, :• rolryQKZ- o/ ^309: '-;`EXTERIOR. LATH
CERTIFICATION OF EXEMPTION FROM WORKERS' -
.coMPHNSA'r1oNINSURANCE.' .:.. -31.0-_.-_...INTERIOR...LATH..._......__... ._. . . _
m,iFsernm need not beamnplemd B,ne,wroth is formic handsd dollars 31r — SCRATCH COAT
(s1 W)or Ins.) •• -
- _ t 313 —_ROOF .NAIL.- ._. ..._ . . . . ...... ...._..,_ . . :.
I cediy that inthe perrotmmce of the work far whim this permit is issued.1 5 01 — FINAL ELECTRI CAlif rENERGY
compensation
its ofr.1dmanymanner sa as to mm
become .a e workers' 502 — FINAL PLUMBING ENERGY
Comns6tion Laxs of Califumid.Dae'
Applicant _ ._... _ ._..
NOTICE TOAPPLICANT:Worker's
after Compensation
this Cedifmte tat he Labor Code,
youshouldmost 503 — FINAL MECHANICAL ENERGY
p � become shbjcmto ywit Worker's Compenwthis provisl shall the Lvbor Cade,you most
fodnwimcomplywimsarnproelsmnaartmspermBsnannedeemedrevaked. 504 — FINAL BUILDING ENERGY
K � ._ I mNSTRucrIONLENDmcAccncr 505* _ FINAL ELECTRICAL-
Iherebyaffirmthatthemisaconstructionlendingagencyfortheperformance 506 GAS TEST
of me work for which this permit Is issued(Sec.3191,Cie.C.)
y p Lender's Name 507 - FINAL PLUMBING
z Under'sAddress 508 — FINAL MECHANICAL
U'O I codify that I have read this appeomion ana sure Ina,me ah"ve mformnio�is 509 — FINAL GRADE
Z.
(.. c6ri I agree to comply,woof all city and county ordinances and state laws slating
OU rohuildingconstruction.andherebyamhorizcmpm,mctivcsofFk,i,ymenterup.. 510 — FINAL PLANNING
W ,the above-memioaed progeny far inspection purposes.
}F. a (We)agrect„sase 514 — FINAL PUBLIC WORKS
W liabilities,judgments,costs and expenses which may in my way acerae against stud
U Z City in emscga<noe"f the graining anhn per ro, .
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. y'
.
Sign ature"r Applicant/Contractor - Data Re-roofs
.I IAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future buildingoccupant store or handle haallous maternal Type of Roof .. -
u defined by the CupediM mpal Coal, Ch n L
9. ,and t I Icahn and Safely ,
Code Section 255321a) �/� ,..- t •�
°Yds I N All roofs.shall be inspected prior to-any roofing. .._.
.. - -_....-
'
Will theapps cant orf i b IMin,occupanl use c9u'p n a e.wbicn If a roof is installed without first obtaining an inspection, Iagree to remove
emit hazardous air corman antsdefined b5 the Bay Area Air Caddy Management
•DRircv ``l ,. all new materials for inspection. Applicant understands and will comply with
I( oyes No all non-point source regulations.
C I have read the hazardous donclu s impt ismenu under Chapter 6,95 of me
Califnmia'Hcahb&Safety Code.Sections 25505,2553]and 25534.1 undersand that
if me building dcesnot tsmly haves tenant,that it is my responsibility to notify the - -
cupamt oft encs xhich mus he met prior t nee of v C nife I of
Signature of Applicant Date
n err au. nnzeatagmt Date, All roof coverings to be Class "B"or better
- OFFICE - - -