00090128BUILDING DIVISION PERMIT
13 U ILDIN i,\DDRP_SS:
PHONE:
LICENSED CONTRACfOR'S DECLARATION
I herby adrtrnt that I.. licensed under Newman, of Chapter 9 (commencing
with Semina ]UNp of Uivi>ion 3 D(the
Ruthlessness] Profeninns Gale, and my license
Lin full force and effect.
le"ne Class U1.11
Dale Col utter
ARCIII'I FC'l'S DECLARATION
1 undcrvnnd my plain shall he uwd ss Public occurs..
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby alfion that 1 um exempt from the Common's License Law for the
following mu sen. (Section ]t 31.5, Buslncss and Profcs Tums Code, Any city or County
w1/nth muffles n per Inc agmn, 11", imprnvc, Acmnlhh, or oeputr any truln c
prior to its issuance. alit requires [lie applleant for wdt pennitmllicasignd"ntmmnt
len he is licensed per.nc m to me pct siaol s 0 the contmmnra.iccn'e Leu (Chamcr9
(commencing with Section ]DI))) of Division 3 of the Business and Professions Cdcl
or that he is exempt rherefmm and the basis for the alleged exemption. Any violation
of Section nO 1.5 by any applicant for a permit subjects the apt team to a civil penalty
of net mom than five hundred dollars (5510).
01, as nwner ill the propcny. or my employees with wages as rbeir nom compensation.
will do the work, tad the structure is not interned lir off mt liar Lack (See 7044.
liminess and I -of ..ions Cndc'. The Comm,nrls License I..w dons not apply m sea
owner of praperty Who bolds or improves thereon, and who does such work bimwll
or through his sewn nnplaye,I.,rm filed that such improvements Ire not intended or
nffercd for wle. IL however. the building or improvement is .slid within one year sof
Completion, the owner -Wilder will have the W rden of proving that he did not build or
improve far purpose of wle.).
01, as owner ill the property, an, exclusively contracting with licensed contractors to
L,nxtmct the project (See. 7044. Business and Prold.wsions Cn le:I the Councilor's
ocnne law does mal appy m an nor, r of Prupeny who bfdlds a improves therein.
and who contracts to, such pmjecu off, a tonuou,sa sl IlanttA pursuant ,the
Contractor's Lima, law.
O I am exempt under Sec. . B & P C fm this reason
Owner Dam
WORKEIVS COMPENSATION DECLARATION
I bonny anion under penrby ul Icor iury Nott'the following dmlamtlorvs
0 I have and will ,at Tin a Cenilicale of Consent to sc -invure for Walker',
Campvmmioo, us provided for by Section 3700 of the Lahnr Code, far the
performanceset the work for which this pcnnil is issued.
01 have and will maintain Worker's Compensation Insurance, as required by Section
ITS) of the LaWr Code. for the m onn:uae of the work for whim this planar Is
Issued, My Wmker'n Confperration Insurance currier and Talley nother are:
phis section need not W completed if the pernit is for line hundred dollar.
(SIM) or less.)
1 certify that in the penomtonce Ill the work for which this permit is issued, 1
slird ten umptoy any penun in any stunner re, w to Wcen.e suhjcut u, the Wnrkm
Compcncnin i Laws clGllip'now. Dam
Applicant
NOTICE TO APPIdCANI': IL after making this Cerificmn of idcm,tive. you should
become wbject m the Worker's Com smicabon provisions of the Lahr Code, you must
forthwith comply with such prow, mors lir this permit shall he deened revoked.
CONSTRUCTION LENDING AGENCY
I heathy allinnthat them is a mnar eflu. lending agency for the perform or,
of the wad for wbiuh thl! permit is Issued (Sce. 3097. Civ. C.)
L endo', Address
I ml that I have read this a,plication and stem ohm the aWve information is
tonin. I agree ,, comhply with all it,, and cuumy odiannccs and stem m v, relating
to Wilding conamednn, and hereby amhorme representatives lir dik city to enter upon
the abovoment bred propere for ingsction no,v e,,
(We) ngrca w save, indcnnity mW keep Wanless Ilie City of Cupertino again"
liabilities, fail ..an..v. ensfs amt ex Penal which may of Tony wiry accrue against and
City in u,nsmquenee of the "noting at avis'noit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signature of Apprcanvcommcmr Date
HAZARDOUS MATERIALS DISCLOSURE
Will he appllc.nt m future building,"rupunt ante lir handle ovemom material
s defined by the C.,cfino Municipal Cole Chapter 9.12, and tIin Halm and Sul try
Code. Sell 25532001.
Ed Yes
Will he .,,]Ivan, lir Tamm W itrl'Ing, «spam use equipnfor or desires which
emir hararsous air ummrninams m JelineJ by rhe Ray Arcn Air Quality \lunagrumen,
Didl
0 Yes I LW
I have read life hr,mth us rnule6cl, Iequlrellc ll under chanter b 95 of the
Cu1il'ornia Ihakh & Safety Cold., S,1ru s 25505.25533 rind 25534. I mobisund that
iI the building docs Bat emmaly have a mount, Im, h Is only roponnibi0ly It, notify dm
occupant of the requircrval, vhich�j dt he t A prior lyissuanee yf a CeryBcum of
CONTRACTOR INFORMATION:
PERMIT' NO.
— AI'PLICSI'ION S11 '1.
90128
SANITARY NO ).
BUILDINO PERMIT' INFO
BLDG ELECT PLUMB MIdCH
1__1
Job Description
T. I.
Sy. Ft. Floor Area Valuation
APN Number Occupant
Issued by:
3690101 `vR!iiWcd Inspections
101 —
FOUNDATION
1.02 —
PIERS
103
— UFER
1.04 —
REBAR
105
— ANCHOR BOLTS
1,06 —
SEWER & WATER
202
— UNDERFLOOR PLUMBING
203
— UNDERFLOOR MECHANICAL
204
— UNDERFLOOR FRAME
205
— UNDERFLOOR INSULATION
301
— ROUGH PLUMBING
302
— TUB & OR SHOWER
303
— ROUGH MECHANICAL
304
ROUGH ELECTRICAL_
305
— FRAME
306
— HOLDOWNS
307
— INSULATION
306
—' SHEETROCK
309
— EXTERIOR LATH
31.0
— INTERIOR LATH
311
— SCRATCH COAT
313
— ROOF NAIL,
501
— FINAL
ELECTRICAL_
ENERGY
502
— FINAL
PLUMBING ENERGY
503
— FINAL
MECHANICAL
ENERGY
504
— FINAL
BUILDING ENERGY
5Q FINAL ELECTRICAL
90T WAS TEST Date
Re -roots Z)Vif — r11VHL b'LUI.1011V1J
Type of Roof 506 — FINAL_ MECHANICAL
509 — FINAL GRADE
All root's shall be 51r0cted Iiri6NlfiLnyFfLkkQ glaih1Crial being installed.
If a roof is installe-A itz4hout ittg Nlfllainl+i( IH1 ibfj1edtlE3RfK5gree to remove
all new materials for inspection. Applicant understands and will comply with
all non -point source regulations.
Signature of Applicant Date
All roof coverings to be Class '•B" or better
OFFICE
CITY DVSONO
CONTRACTOR INFORMATION:
BUILDING IIINPERMIT
Buy�I�n�8D8RE�sORRE AV
- —
PERMIT NO.
00090128
..[0
E:
APDATE
p
PLICATION 1
BONE:
SANITARY NO. CONTROL NO.
i0
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
9G
BLDG ELECT PLUMB MECH
o u
ilia.
2
..rLICENSEDCONTRACTORSDFCLARAr10N
'�. -1
Job Description
Thereby IT.W thint n.ed unJ po' s f Chgph,, 9 emmencin8
T.I'.'f-
U.,is
ih5ctto)*hofDs fthe Bs :andP t . tCalc,ondmylceno,
to nlrrce ard effeci..-.
,
x6
N
License Cl L a
Data S Commerce
ARCHITECT DECLARATION
��
eao
e
e
I undemmnd ml plan shall be used at, puhl c rcusNs
Licensed Pmfeaional
RATION
OWNER-BUILDERfrom
z <
the Comment's
1 hereby eRnn the 1 I.S.aempt tram the Contractor's License Law for the
]1131.Business and Professions Coate: Any city or county
$3500
FO
following reason. (Section
h 9 pe I a 1 hr'tp Ya crate
' -' ._ `_..-.
a
pat alsore9 the .,mic rf hpe a Tle grcd.mr mens.
go,
n t ' r. us p, (Ch pter9
lhan Tc Scdpu. nn tit p son. fth "comm'
Bn a Profers Coon
M t 3 �� $ �'' A, �.
Valuation
dont .nein m sea o 7111) orDrvision 3 n the ons
a gw es.
or that he is therefrommrd the basis for the alleged
or Any violation
,
i I.r t': k. at ,
1014pN 11100RTDATION
Occupancy Type
3 .. l"faco
, than by any applicant fur a permit mbJcas the applicant to a civil penahy
of no rim,
.or not marttnanfive hundred dollars as(m).
❑Lnssm'netonnepmpeny,nrmyempwraawhnwasesasmebsomuompeasatmn,
102 — PIERS
..., .
103 — UFER Required,Inspections. + "'
-will do the work. and the swcmre is not intended or offered for sale (see. roti,
Business and Professions Code: The Contractor's License Law does not apply to an
owner of pmorcy who bald, or improve, thereon, and who does such work himself
104 - REBAR
'
through his own employees. provided that such improvements are not intended a. or
or offered
domedrorsthe.ovnowuildethebuddingorimanofpemnsold
- - .. �-
.- ... T05 �= ANCHOR BOLTS .... .
hedidtome>eaor
icompletion, the owam".1der will have the n.men or proving that he aid not build or.
106 — SEWER & WATER
•
mprove for purpose of sale.). ,
- � per y, um exc usiv y with licensed commnars m
oi: as owner of inn t I <icontracting202
"— UNDERFLOOR PLUMBING
construct the pmjcct (Sm. 7044. Business and Professions Coate:) The Contractor's
203 — UNDERFLOOR MECHAN I CAL " ' '
_
Licari law does not .pply to an owner of proprny who builds or improve thcrtan,
and.who. connects m, such projects with.a condemns) licensedpursuant to the-
204 - -- UNDERFLOOR FRAME . -- —
Convectors License Low.
❑lmoesemptemberSee ;B&PCforthisrtawn
205 - UNDERFLOOR INSULATION t:
Dom
301 - ROUGH' PLUMBING ,.
' - 'WORKER'S COMPENSATION DECLARATION
302 - TUB& OR SHOWER
Ihereby afrnnunder Penalty °fperjuryone othe following aeelaraeons:
303 - ROUGH MECHANICAL
3 1 have uad will main . Canificae of Consent to self -insure for workers
304 — ROUGH ELECTRICAL
1'�3700
Compensation. as prea int by Section 37W of the Labor Code. for me
°rm
305 — FRAME
reformana of the work for which this permit is issued.
_
306 - HOEDOWNS '
❑ I have and will andamin Worker's Compensation Insurance, as required by Section
of the LaMr Code. ter the pc,fonaat« or me work ror which this permit is
3 0 7 — INSULATION . .
=
issyaMyWorker searnpcnsationInsurancecamciandPolicyaumberare., _
,.-
. -. -e... _. ....._ .. ..-
308` =. SHEETROCK " - r .. .-.'.
C�r 3jCERTIFICATION
t •s• '•3,O9 r'2 caEXTERIOR''LATH'
OF EXEMPTION FROM WORKERS
.
.': COMPENSATION INSURANCE'. , '
_ _. ...___3-1-0---;INTERIOR_..LATH ..__._-.___..._.__ _._., .._-_._.
•I .
'(This smash need nota completed if perms is for one hundred dollars
311 - SCRATCH .COAT
510('oy"'.)
-- 313 - ROOFNAIL -- -• • • - - _"c
" -I certify that in the perfa .mor ofine work for which this permit is issued. 1
t 'tQ':. ��
314 - T -BAR CEILING
so
•ihall not employ any person in any manner so as to become subject m the Workers'
Compensation Laws of California. Dae
50.1_- FINAL ELECTRICAL.ENERGY - ..
. Applicant
NOTICETO APPLICA.vI':ILa(tet making tnis Cenifcate of Exemption. you should
_
502 - FINAL PLUMBING ENERGY
0
become spbjca t° the Workers Compensation poi of the Labor Cade, you must
f onh.ith comply with sach provisions or this permit shall be deemed revoked.
503 — FINAL MECHAN-ICAL, ENERGY _
i i
•' CONSTRUCTION LENDING AGENCY'
504 - FINAL BUILDING ENERGY -:
>
hereisacoctionlendingagencyfortheperformance
thereby nsw
Ihm
of the Sm.work for which Nis permit is issued m. 3097, Cir. C.)
505 - FINAL ELECTRICAL
O
Lenders Nene'
506 - GAS TEST.
Z
zaadrsneares
507 - FINAL PLUMBING'''
I mmfy-d.; 1 have rcud;lo, -priscaomin ad same �har de above information is
'aomm,. I agree to comply with all any and county mmimemes and sure laws relating
508 — FINAL.' MECHANICAL -
U
to building conswction, and hereby authorizercpmscntativesofthiicity menter upon
509 — FINAL GRADE
W
a.
the .1w c-memioned ProPeny for inspection pmlo s,i,
(wd)' agree tos2p.endemnifyaadkcaphumleatheCity 'ofCupntinoagainst
510 - FINAL PL ING
Z)
7.
liabilities, judgments. cost and expenses which may is any way acre against said
City in mis,acmiam of the graining of thin perms. ,'
rj 13 r NA
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT"
"71,
Issued - Date
SOURCE REGULATIONS."'
Re -roofs
Signature or Applic.nvConactor t Data
' HAZARDOUS MATERIALS DISCLOSURE
Wel the applicant or more building (weeparrt store or handle Ivezuraous material
. Type of Roof .. ..... ... ... - •, .. . -. .. ... -....
'g as defined by the Copenino Mankind Code. Chapter 9.12. and the Health and safety
• ° a.
Code ❑Y r 25S321aj^ .
°No•
[ . .
f •
All roofs shall be inspected prior to -any_ roofing material being installed.
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection",I agree to'remove
emit baurelous air connotations as defined by the Bay Arca Air Quality Management
all new materials for inspection.,, Applicant understands and will comply with
all
+
Distinct?
Yea - ❑ No
all non -point source regulations..;
V
1 have�mad the hanNous materials mquimments under Chapter 6.95 of the
'C.lifomia Health & Safety Code, Sections 25505.25533 and 25534. 1 understand Nat
_ - -
if 4he building does not comely have a tenant, that it is my responsibility to notify the
bacupam of the 'T c omemctns which must he rima prior tb issuance of a Certificate of
aapan=y
Signature of Applicant Date
roof coverings to be Class "B" or better
Owner or uutboazad agent . DataAll
OFFICE