00070184CITY OF CUPERTINO
CONTRACTOR INFORMATION:
evn,DINGDIVISION PERMIT
x UILDING ADDRESS:
PERMIT' NO,
OWN17R'S NAME:
APPLICATK 1
I�6I"dTU164
1153rD UPLAND WY
IONS:
's}Q71281�'S I�.
SAN] EARN IOO
BUSCH JOHN P. AND WENDY L
Z
ARCM TECOhNGfNGRR:
BUILDING PERMIT INFO
O
BLDG ELEM I' MECII
F
v
11
LL— I_I _ ICJ
IdCENSBD CON'TRACTOR'S DECLARATION
Job DeSCI'Iph On
hereby nlllrm thin i um licensed under Ptnvi.ion. of Chtpte, 9 (...... uing
i1
with Suction f Division l of the Bmincss and 1'ndcasiom CsvJc.:uW shy licvn.w
<
)lane
L' in full forte and effect
Cl.. Lie.» 3a 1
mcn.e _CeK�na.�lw
_77—iLt/ o Conrnemr_s
nRCHI1:11 DRCLARn'r1ON
BATH
REMODEL
g
I unduraand my plum shall he used as public record.
O Liaxmed Professional
OWNER -BUILDER DECLARATION
Lo
1 hereby affirm that I am exempt front the Commetor's License law for the
follewing reason. (Suction 7031.5. Emilie, and Prel'espions Coch,, any city fir nmntY
M
which "aims a permit to osmtmct, slie, improve, rlenmlish, or repair ..try xuuemn,
prior in as issuance. also ermines the applicant for such permit to file a signed statement
- Sq. Ft. Floor Area
Valuation
- that he is licensed pnnmmnmlhelmtvision.ofthe C ... mcmrsLi,cnscLm, (Chapter 9
(commencing with Seetina ]IgUl tilDlvipion 3 or do Rosiness and Prnf essiom CV&)
m that he is exempt therefrom and the basis for the alleg'e'd cxnnplion: Any violation
of Section 70315 by any applicant for a pcmhil .subjects the applicant m a civil penalty
APN Number
Occupanc
or.mt mmman me hundred mdm,n(S51S).
5 O6Tpe
C3 1, asowner ofine Nunnery, or mycmployccs with wagesas their%olecumpcosaliun.
hp eegnlred nspections
will do the work, and the suucture is not intended or offered for sale (Sec. pill,
Bminess and Itedemionr Codm'I'he Cmitrnetor's hittnse Law does not apply to nn
r oI'pmpany Who builds,,, impmsc thereon, and who does act, work himself
36651005.
tL,I�I
or through his own employee%. provided mastich impoevement%me not intended or
offered for sale, ir, huwrvur, the hui ilm, or improvement is old within one year of
iomplaine, the o vin,,l uildcr will have me burden ,,f proving thin he did inn hoed in
1.01 —
FOUNDATION
mprove for pamom nrwle.).
01 ith pno,crt,antI,'v%ly,enn,.,fln,whhl 1 ..,mr%te
1.02 —
PIERS
Lint u l th project (S 7H4 B ss J P I'.. m[ J )'rh C noun,
-103 —
UFER
ax L,ov does not applyt ot pro,peety, who buil)% in imprtoc.mcnron,
and n contracts r n projects 'int n t aa) licensed personal to the
1.04 —
REBAR
C..ora, nr.. I, ac tie Law.
G l am exempt under Sec. '.B&Pc lot his ren."'.
105 —
ANCHOR BOLTS
owner Dale106
-
SEWER & WATER
WOR KIiR'S CONI PEN SAI'I ON DIiCLAR N[ ION
202 —
UNDERFLOOR PLUMBING
Inhereby affirm under penally of crit, one of the following declarations:
khave and will maitmin a Ccnifi,du of Consent to evilimam, for Worker.
—
UNDERFLOOR MECHANICALContpensatbn,
n203
m provided for by Section 3700 of the "for Code. for the
204 —
UNDERFLOOR FRAME
performance,f the wad I,,, which this penelr is issued.
20S —
UNDERFLOOR INSULATION
❑I have tindwill maintain WorlerxCompensation Insurance, asrequired bySection
nal of he Labor Gide. for he perrnmmrce of me work for which mix permit i.
301 —
ROUGH PLUMBING
issued. My Worker'sCis a,,so, tion loo ti currier and Policy realer are:
l r rA..c Y4Y28_k=17-17i
t_ Pnllcy
=%02 —
TUB R OR SHOWER v
carrier:_ _
cER I ION _ _ _
crxnrlcni lord orcxEMrnoN FROM woRl<ERs303
—
ROUGH MECHANICAL
COM ITNSATI ON INS U RA NCB
304 —
'
ROUGH EI_ECTRICRL
(This cation nveJnot he enmpletaJ if the permit i. for one hundred dollars
305 —
FRAME -
auX9,r le...1
-
1 curdy that in the Iwf'ommocc of tee work In, white this pennh is i ... ed. 1
306 —
HOLDOWNS
%hall not employ any person in any manner so a. m become %abject uh the Workers'
307 —
INSULATION
ContpcnanndLime'.1California,Dat.
Applicmn
308 —
SHEETROCK
NOI ICE TO APPLICANT. If. after maki.,,hi, Cenifiemeof Esemptior. ,at should
L
hecomesubjca mthe Wodsr's Compensation provisions of the LaMe Code. you must
309 —
EXTERIOR LATH
O
ronhwnhaomplywithiacltprwision.nnhi.iwrrtilehall edeenedrevnked.
310 —
INTERIOR LATH
m
CONSTRUC-HON LENDING AGENCY
I hereby udlnnthan h. is a enmtmcrinn leading agency forme perform.nee
311 —
SCRATCH COAT
wk tetv
ter roe in r wni,li this ear i. ia..rted (Set. 31193, C. C.I
C
Leader', Name
313 —
ROOF NAIL
Z
Lender's Address
is
501 —
FINAL ELECTRICAL ENERGY
p.
1 renity that I have need mi. application and auac that the above information
correct. 1 agree or comply with all city and county ordinances and state law, reciting
502 —
FINAL PLUMBING ENERGY
V
to building comuuctiort and hereby umhoriec mprescmanivs of this city uh enter upon
W
meth,,n.ni cdpnipnyfin impcmionpur,ah%c^'
^ 503 —
FINAL MECHANICAL ENERGY
y
lq
(Wgagrccm cod, aunilytindkvhuhnmayinan .y ccuperlinun.moat
liabilities. judgments, axes and eapcncea whmh may in any way accede agaimI mid
`J 504 —
FINAL BUILDING ENERGY
'Z
Cay in con c,tem:e of the gramag of this permit
AI'P WILL MPI WITII ALL NON�P(INT
by: 505 —
FINAL ELECTRICALDate r 1/
BIC
Re
.SL
1906 —
Re-roofs507 —
]RS TEST
FINAL PLUMBING
I.
/ ��
.....atom m�/Date
�HAZARD(ATERIALS ❑ISCIASUItE
willthcii,dicantin future huildin, ocorpan .7070 or handle hAtimms mmenal
a% deleted by the Cupertino Municipal Calc. Chapter 9.12. andme H,.hh and Safety
Type of Roof
508 —
FINAL MECHANICAL
0.1, Section 2553210^
O Yes 0 N
�tee�� ecl,1 rr�311 � r- �5e
All roofs shall �L DISp�'ctEd�M R -to F1A�!%Bing material being installed.
Will the applicant or future building occupant use equipment or devices which
If a roof is insSIcO withfii fn- l.obfeilnhlVUihlFpectionr 1 agree to remove '
mit h:vmJum air contentinunm a, duf.cil by rho Bay Area Air Quality Managanem
iancc
all new materiM* impFc:IiNAL,L,rrpliMtitlf(WeWRAEDnd will comply with
❑Yes 0 N -
all non -point source regulations.
1 have rind the haeordon% nnnerlaH tegoim..mm. umler Chupmr 695 or the
"
California Health & Safety Cal, Sections 25505, 25533 tied 25534. 1 alibied that
if the building hies not cmtendy have a i nam. thin it i, my, rcsponsihiliry m notify the
orcnpum of the r,,u,rcnmms which must he met prior m is%mace of a CeniCmme of
Occupancy.
Signature of Applicant
Date
All
roof coverings to be Class "B" or better
owoer,r ,,.slit Date
an❑tod:.ca
urrlce