00080162 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
HU I LDING ADDR,FSI; PERMIT NO.
000801 FiP
OWNER'S NAML, x APPLICATION SUR DA'1'a
IIHONF,: SANITARY NO. ,C(WIIGI.NO.
�DOF ARCHITECT/ENGIMEEX - BUILDING PERMIT INFO
I_' 1
Fyj I,ICIiNSI:D CONTRAUOR'S DECLARATION fob Descrlptl n
COOH_ 1 hereby Clio,IM1m 1 am licensed un:kr prnviaione of Chap¢r 9lcnmmencing
iso Fui with Seer n](IUfl of Division 3ofthc Buvinca vnJ Aofessiom Cale,aal my lieenw
s Y ] iv in lull forte and effect.
Faemecrosa Cent gDDITION 499 SO. F
3 a v Dmc Contractor
5
F G ARGH111 he u e a,public T1od
J I unJcrs,:uul trig plum shall he used ns public ncnrds
r
1;eatscd Profca.innul q7
OWNER-BUILIIER DI;CLARATION
a W I limehy affirm hit,I am exempt front the Comercmr'.License LWw for rhe
F% following reason.(Section 7U31.5.Business and professions Code:Any city it county
Ex o xhiih requires a penal to<im,mav,.alar,impose,demolish,or repair any structure
ceprior to its issuance,also requires the applicant fir such Federal to file a signal statement
mm he is licensed pttreuanni the pmvis,nns(if he Control License Lt.(Chapter a Sq. Ft. Floor Area Valuation
(a,m anteing with Section 7001 of Division 1 if the 0ueiness and Profession,Code) -
nr Ilow he Is cxc apl hl a'cfmm and the basis for the alleged exetalema.Any violation li,1. ck n
of Section 7031.5 by ung appllcanl lou a ple,od,nab,M,the applpcnnt 110 11111 panully
,if am more dean 6chnmlmddollar,(S5UU), APN Number Occupancy yPe
❑I,asownerofthe aa,.y.,am,employee,'ruin wages m dulv lu,roatum.
will do the work,and the structure is not inlcadel or offered for ole(Sec.7I414, 321510 -33
B.,incsa and profession,Code:The Cemr¢mr's License sow-does nit apply to an Required Inspections
owner of progeny Who M1uilds or improves thereon,and who does such work himself ,
it through his own employeesgroused that such improv rarems art not intended or
offered roe Bale.It,hosteler.the building or improvement is sola wilhm rine year if 101 — FOUNDATION
ah,.p'lion, w owna.m� de,will hose the b�nleno,rprivi I,that nidid ma head or 102 — PIERS
ll e for pumi,c nI sinal.
❑I,as Owner otthe pct,perry,am exelu,ivcly cmtmeang wuh licensed contractors or 1.03 — UFER
I,icemet the pi,iart(Sec.7044.Business and profession,Ctde:)'rne Contractor, 104 — REBAR
mac Use chess our appy if,an moan,of pmperty who builds or improves Immon.
and who contracts for such projects with a control licensed pursuant to the 105 — ANCHOR BOLTS
Comracmr',License I.uw.
❑I WE exempt under See. ,B FTC for this reason 106 — SEWER & WATER
Owner Date 202 = UNDERFLOOR PLUMBING
WORKER'S COMPENSNION ACCLARATION
203 UNDERFLOOR MECHANICAL
I hareby ofirnl all,penalty of perjury ane of the following daclaraduro:
—
: I lime and will maintain a Cby Secti of Consent m srtf luoure for Workers
^104 — UNDERFLOOR FRAME
omprrance o. as pork to, for by s«tori ria0 it the Lulw,r cede..roh the 205 — UNDERFLOOR INSULATION
mmaieifine otkrorwnilntni.pnnili,i,xnd. 301 — ROUGH PLUMBING
❑1 have and will mammin Worker's Compensation Imemove,as required by Section
37X1 of the Lnhor Coda.for the perfmmaaee A he work for whirl,thio pinna w 302 — TUB X- 0 R SHOWER
listted.MyWtaka•,C.,ntpa,taro.. asmenacanetandPooeymmhherrc: 303' — ROUGH MECHANICAL
ca,d.= CI!RTng0AT[oNOil EXrml'I]ONFROM WORKHRS' 304 — ROUGH ELECTRICAL_
CONFIENSATION IN 305 — FRAME
finis section rice]nm he cimplemJ ifthc pirout is forint,hundred dollars 306 — HOLDOWNS
(81(X11 nr Icsx.)
I coaly 11 1 the poNrtnance of the work ear which th1C pemdt it issued.1 307 — INSULATION -
tlI ria amploy mty p.rson in airy t,I r baa loja,on;Mar to he work... 308 SHEETROCK
compo,+atioa Lnwx m Caltlneni i.oya,
Appheam —�° �- 309 — EXTERIOR LATH
N(y110ETOA I Compensation
%of the
-
Z he.imesugeermthe warke.,cimpensationprilisionxonnrLan.,rr..,de.you must 31.0 — INTERIOR LATH
0 forthwith mmNy with such provisions it this permit shall be deemed mokcd. —
CoesTRUcrIONLrsNDmGAGENCr 311 SCRATCH COAT
> 1hembyv0irotthat thereivaconsmaio.IenJln,agcnryfar the peronionce 313 — ROOF NAIL
W of(be work for which his pv.n ut is i,sued(see.30yl/,Co.C.)
o p Leader',Ni le 501 — FINAL ELECTRICAL ENERGY
5 7 Lendcr',AJdmss —
502 FINAL PLUMBING ENERGY
C.1 I I.,me tbm l h:comply
read all city
it plicstiin an fro,ondir rbm the uMwc inmal halon is
O v orWild�g couvNcao�hnamm�Y ahou,n. t<pvient°+ve:oin°state�o enter�po� 503 — FINAL MECHANICAL ENERGY
y theaame-mentioned progeny farin,gectionpropose,. 504 — FIN BI_IILDI ENERGY
E„� y (We)agree lir save,indemnify and keep harmless the City of Cupcnino against —
rn laniliaes,jangmem,,mos and expenses wlant n,ar in aay way aartte agwna,aid 505 FIAl. ELECT CRL F ^f /�
U ZZA (CANTUNDI?Rtil'AND$AND WILL COMPLY WITH ALL NON-POINT IssDCd by: -906 — GA Date � - yOmo ornpplmail/ n mit` na,e Re-roofs
HA%ARDOUS MATERIALS DISCIASURE 508 '— F I AL MECHANICAL
MSR the applicant or future building occupant xtam or none ha.amam nominal Type of Roof 509 — F NAL GRADE
m defood by he Cupertino Municipal Calc,Chupmr 9.12.and the Health and Salty
Code.Section 25552m)? q l
OYea 0N All roofs shall bc9iins[ected f{C�rFiUr�1�[%anvrPlo'r]i1i : rial being installed.
Wulf love,lieumarfilm,haddiugo.a.g,anrrise i'a'ne (ad.......tier if a roof is installealAthou['11151•M�tlli 011"'Y111��T3pe�°�Sb�i��grcc to remove
anis hamrthe,Dir cinnnnin;Dns us Aellnc.l by flue Ray Arca At,credit,hlunnpunem
Di.onet, all new materials for inspection. Applicant understands and will comply with
area 0N all non-point source regulations.
1 have head the hmurdous ammonia aquircmcnts under Charm,6.95 if the
California Health dh Safely Cale.Sections 25585.25573 sad 25534.1 undccaend that
if the building does not currently have a tenant.that it is my nesiami lily to nosily the
01 am of the requiremmu,a which triad M1c rite,prior to issuance n1a Cenllicete of
°p°"`y' cro Signature of Applicant Date
c
oxnerorumho,i.edagem C — D,m All roof coverings to be Class "B" or better
OFFICE