00030170 CITY OF CUPERTINO PERMR NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: 00030/ 70
BUILDING A°DRESS:
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SANITARY NO. APPLICATION SU�BMfITAL DAT(
O 'DR'SN
1��� I ✓•.•— Ave
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Q G �J� BULDINC PERMIT INTO
ARCHITECT/ENGINEER
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F N i LICENSED CONTRACTOR'S DECLARATION
Z =0 I hereby alum Naz 1 w licensed ander provisions of C o&. 9 mylimnmis Job Description
FyCw with gctic and'Iat'Tvision JafNe Business aid Pnfmias Code,W my lucent is /,/yT .ten 7r .
Q Y J In fiY11 Tonne Lal CBt[t. � i/fV��(ij(//
s m< Liceve Lic.N
3 u y D,u Con.
bi
i-u On CHrtECTS DECLARATION
zce
a I un u D 3 ingt1 he used as Wblic ucads
d'n o ens dProren nal �•f��
u�: OWNERBUILDER DECLARATION
C 3 G 1 hamhy afftmt Nat 1 em Com"from the Commuter Licenu Law for the
h❑ following=am.(Section 7031.5,Busines,and Profession,Curie:Any city on Monty
w which requires a Ionil m cotnwe,eller.improve,deonnlish,or repay any stmeture Sq. FI. loot Area �1 ViAlui1I1017
3- prim 10 its issuance,also rectums the applicant fmsuch pecom m file a signed statement Tt t��yJ{tr/�
Nn ue ix licensed puauam total proviaimi of the Cmnactor,License I�w(Chager 9
(commcncingwithS bon7")ofDivisim3oftheBusln "a fmiomCa )mepNNumber O LupancyType
da, mM he Is Canals therefroathe basis far the alleged exemption.Any vinAmon of /` _O 3a
Smoon'/031.5 by any epp0om for a partum ijocu Ute applium to a civil laundry of /✓s
aw wane Nan Bva hundred dollars 135001
I,asowturk,and
pmprty,ar my Conplayus withw,guumei(Sm. (imp,wtim. Required Inspections
will dothwork,am Nese,Con isnmi Licens Law does
We(Sit.to an,ramera
ness
and a Itreeny who
Code:The ove,Went
and w o dos such
nit apply m lf owner d
his o ny wW build,m immdvth therto.,W who does ruck wort himself m though
his own employee,provided or improvement
such anent is sold
art m inurdW m pRcrW for
om If,howeverthe building orimpovemem iuold within me yet of rompletion,the
neralilo) will have the burden of proving duet he did not build or improve for per- ,
Wm of sown,
I,a owner of the Sm.7Prolixity,.Business velynd Connecftfointing with:)Tut,,Communes m
..oval Ne project(SM.o an noofend rty wW nt,but&m uThe Cmwcrol, nd
cent Law d«s rot apply je ts owner of pm or(s wce builds or improves tMrton,end
whoContracts for such pmjxu with.cmtsecdor(a)licen.ed Wrswnd m the,Contra<dors
License cion /
0 I un exempt under Sac. .B h D C fw this mason
Owner Due •v1 V
WORXER S COMPENSATIONLA
DECLARATION O
1 hcmbyamnnendopeall ofpfco ateof Nefsmviogdecle sco
'un I have anal will for b l Section
37W of ComenuoCr f.far
Wdo.Comp'be
duan,as pmyidd for by Section 3]00 of Ne Labor Calc,fm Ne pcdomunce of the
fcawhich this leant is i of n'
I
have and will meinuin Wotkci s Compenution Imurance,u ryuimd by Section
J of the labor Coda for Nc preare ttof the wmk fur which this permit is inmcd.
My W. f/PJ} eti Insurance cerdcr and Policy nupgG..x:
Carticr.�• Policy No: fwcTR Sr
TIAAII '��f XBMPTION FROM WOR(ERS
Nv - -COM E ATIONINSURANCE
(This maim Conduct kmeepletedifth.Permit in fmmehurdMdollou WWI
or les.)
I Certify But in the pa formanM of the walk for which Nis pound is issucd.I shall
not employ any person in any manner W as to become subject to the Workera Compcn-
sali.n Laws of Cdamaie Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of ExemPtim,you should
become iniac,to Ju Workers Committed..pmvi,imn of Ju Labor Code,you mon
fmhwidh comply with such provisions or this permit shall W domed revoked.
CONSTRUCTION LENDING AGENCY
0 (hereby uffmthm them is a ConstrvNon lerwing agency for the pcdomuweof t
Z tithe work for which this potion is issued(Sec.306],Civ.C.) -
IeadersName I
s Address
G I I,
W4 Fz Lender1 certify thu 1 have read Nie application and note that the above idomud..is 1 '
L Coact,I agree to eomply with all city and county and tures W ince laws rtlaung to U
U Z Correct,buildi,meuuctioa.and hereby aaJwrim mpueentNlves of Ni,cily fo murrtpon the MAR $ 2000
U o spore-mentioned propcny for ryu
inspection puoa.
W. F•, (We)item,to save.indemnify and keep noon).the city of Cuomo"against
U liasilitio,judgnnnu,emu andeapeus which may in my way accrue agd.said City
} W in Consequence of Ne granting of this permit.
F•' 0. APPI.ICANTU ERlTANU ANOWILLCOMPIFWifIIALLNON-POINT E3
U Z tiOt tCEP UI TIONS. _. - n
Sign um ofA IicanUCon dmi au ,
HAZARDOUS MATERIALS DISCLOSURE
Will the alphcant or foam Wilding mcupant nom or haMlehwdous moons) Re-roofs '
as dcfned by the Coleco..Municipal Code,Chapter 9.12,and Ne Health end Safety Type of Roof
Code.Section 25532(.)9 YP
❑Yea ❑s6
Will Jc slopliciont or four,Wilding occalmt use egtipm,m or devices which All roofs shall be inspected prior to any roofing material being
crown hnadous air conuminans as deNcd by the Bay AmsAf Quality Slanagentens installed. If a roof is Installed without first obtaining an inspection
District? pxfI agree to remove all new materials for inspection. Applicant
Ovemudthh. .ngaimm nrsunderCh q h.95.fJuGali. understands and will comply with all non point source regulations.
fmnin Heeldh R Safety Cade,Sections 25505,25533 and 25514.1 uMmtard this if Ne
huile"' doe nendyh unant.Nat it is my rnpmaibiliry nmify vpant
of heyyff�d�u�; ''It t prim w iamarce of a if to f ry.
�..�kc Signature of Applicant Date
net r o No uM egend y Dau
All roof coverings to be Class"B"or better
OFFICE
CITY OF CUPERTINO
• 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: nancyc
COPY # 1
Sec: Twp: RnU: Sub: Blk: Lof:31606039.00
DATE ISSUED....... : 03/28/2000
RECEIPT 8.........: 11819
REFERENCE ID U ...: 00030270
SITE ADDRESS .....: 10435 N TANTAU AV
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ...... ......: BAY 517 CORPORATION
ADDRESS ......... .:
CITY/STATE/ZIP ...: CUPERTINO CA, 95014
RECEIVED FROM ....: JERRY
CONTRACTOR ...... .: LIC It 21546
COMPANY .......... : GORDON-PMU INC
ADDRESS .......... : 1245 PEAR AVE
CITY/STATE/ZIP ...: MT VIEW, CA 94043
TELEPHONE ........: (650)335-1990
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW HAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 95,000.00 770.00 0.00 770.00 0.00
BPLANCHK PERMIT FEE 770.00 654.50 0.00 654.50 0.00
BENERGY PERMIT FEB 770.00 231.00 0.00 231.00 0.00
P""'ACOVER NO UNITS 2.00 28.86 0.00 28.86 0.00
I COM VALUATION 95,000.00 19.95 0.00 19.95 0.00
IXT NO. FIXTURES 6.00 6.66 0.00 6.66 0.00
BREMRECEPT NO. OUTLETS 32.00 30.24 0.00 30.24 0.00
BREMREPALT NO UNITS 8.00 97.68 0.00 97.68 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT 183B.89 0.00 1838.89 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 1838.89 7709
............
TOTAL RECEIPT 1838.89