01070007 (2)CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION:
BUILDING ADDRESS:
PERMI"1NO.
23666 BLACKOAK WAY
01070x0/07
Onk1V & MELANIE PURCLY
A07c%05/2001
PHONE:
SANITARY NO. CONTROL NO.
Z ARCIIITECI'(ENGINEER:
BUILDING PERMIT INFO
2
BLDG ELECT PLUMB MECH
i LICENSED CONTRACTOR'S DECLARATION
Ob DBSCR hOn
Inereny ardm, mal loon heensaa ander pramsmns orenamer9matnrne"`i"g
INSTALL OUTLET }rOR B.Vion WATERFALL.
ce with Section 7000)of Division] ofthe Business and Professions Cade. and my license
in mnm,ee and effect, 77• �/r'
0
& GAS OUTLET FOR BARQUE.
u Liceit Clas: Lid. #
Uum GN <
G l
as ARCHITECT'S CLALA RATION
DEDEC
understand my plans shall be l as blic corJs
� I understannsupua
L L C(—
7 C �
'O
Licensed Professional
OWNER -BUILDER DECLARATION
(/
as I hereby affirm that I am excmpl from he Connector, License Law routine
< fall.,.., reason. (Section 70315, Business and propellers Cade: Any city or county
wInch requires a carbon m amtlrvdl, the,, imp t..r, drowlixh, or apcir any stntemrc
..Prior ma, Issuance, also recuses the applicant Nor sueh permit In File a,igned stmement
S Ft., Floor Area -
Valuation
- ,hit he licatisedpar. tto the nownsion, ofth Contractor s License Law((`hapter 9
'g'
c hSefl70W)fD 3 Rh li.'ess a" Prum,,im Cod e)
;p", e 't L�'f I_., ion,! ,}s"
or that he"s evimpt th efmm and the bas's for the alleged esamplon A,yvcal
- vs
15,
of Section 7031.5 by any applicaal free permit xubJsts IM10 applicant m a ervll penalty
proclaims, than Toe hundred dollar_, (s500).
APN Number
(.'- Occupancy Type
Cl 1, as owner of the u operty. at aty employees with wages as their. sole compensation,
516 - FINAL BUILDIN
- will do the work Indtoostmewre is not intended'., voromb for sale (See. 7044,
- - -
Required Inspections
Bu s and Prof .. Code The C I Licca,e Law does an, apply to as
owner ofp p ty Who looddis or opinions thereen, and who does such workM1nmser
or through hs res n emp13 provided that h improveracents arc no( intended or
offered bI 11 however the building p t is : IdIh of
completion, the6 ld will have theburden fproving that he did t�ildor
`
'hapboo for clothe),
t
❑I arsooierforoffin pty, I IIIlicensed ...... ',
I the j t (Se ]W4 Ravines, d Prom... Choice) Th C t I 's
d L 1s I aniflyt fD oety h builds p N
_sly
and h contracts f such projects with mnmgs) licensed pursuant to the
_
Contractor, License Law.
/.
- ❑ Iran excmpl ander Sec , B & P C for Ihis reason
'
Owner Dam
WORKER'S COMPENSATION DECLARATION
'
1 hereby affirm under penahy a(perjury one of the Nollowing declarations
O I have and will mountain a Certificate of Consent to self-inwa for Worker's
Compensations, as provided far by Section 3700 of the Labor Code, for the
performance of the work for which this permit Is Isawd
Ell have Ind will nminmin Worker's Conipensminn hrocaoce, as oviLdre l by Section
3900 of the Labor Code, for the Nafonnanoo of the work far which Ihis permit is
ead P
issued. My Worker's Can or and e:
y number arp.ncmnon In, en
_ ..-. .. :.,
Curer - Policys.-
.. ._
CERTIFICATION OF EXEMPTION FROM WORKERS';
5 , r
---•, _,' COMPENSATION INSURANCE is
(This ,,ni. head Dai be arinclened f maporn't-s France hnded dollars
..
($1(IO) or lLss.)
,• 1 certifyill' the H ce of the kf 'lt hth
P Ie Ivin d1
„!
'Juall t mol y' y p any tion me n o t the- tiara
'
Com top� q� Il m nl /ry._{{J��y�`/1
eA'
.App1� I afM1 I J1 i�c
._ .. ..
NOTICL T , PPLICAN I.alaar naQ7lb, n l cam at Earaption, Yon.Shat Id
become,occat In the Wn,ko i Compensation pmv.slons of the Laboh Cods, You muss
trillionth th comply with sueh provisions .,this perun ondl be deemed revoked.
COn LENDINGAGENCY
here is area
- thereby a(fmm that thereisa nonanSion 309th ngapaacy Guam perfonnnnce
" work for which Itis pe6nil iu iecueJ (Sec 3[19], Civ. C:I
Lethe
� Lendeis Name-
Lender'sAddre¢
1 certify that I have and this application and.ama that the above inforntatire is
rtect. I agme ,, comply with all city and coemy ordinance, and state Incas relating
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to boa lohng ®nsvuution, and hereby announce, representatives of this city to enter upon
] the above-menlionul property for inpmtion purpoms.
(We) agree,, cove, indemnity road keep cal mll" the City of Cupertino against
7 liabilities, judgotents, oasts and expenses whole only fanny way ..cone rgoimt mid
City PLICAnscy NDERcure fthe gDS AND tILLCOlt
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
��
ISSLICd by:
SOURCE REGULATIONS.
Date
Signuwre nfAoplicanVComrnemr. Dale
Re -roofs
HAZARDOUS .MATERIALS DISCLOSURE
will the ohyl.... m or for I building oceapaorstore or handle haiendar,ricanal
Type of Roof
as defined by the Cupaa.no Mun'mipel Core. Chapter 412, and the lanith and Safety_
code ovis
�'2ss3z(I "'- I t
It
All roofs shall.be inspected roofing material being installed.
Will In, poli hit I to lifirs, Carlaipaid alleq p t or ballots which
J
If a roof is instalted' Svithout first obtaining an inspection, I a ree to remove
P g
em t cc oat as defined by he Bay Area A' Qtr ty Manag Dent
Dict, ct,
E,
all new materials for ins inspection. Applicant understands and will comply with
BP P Y
❑Yes �No
all non -point source regulations.
1 have read the hazardous m aerials reyuiremeen. under Chapter 6.95 of the
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Ca11ona Health & Safety Cale, Sections 25505, 25533 and 25534 1 understand is,
if the building does urn a bendy have a tenant, that it is it, responsibility at mail, the
-
I mac be mat od�rm Ixsnunce n[ a CenlEcmc of
11i I<�
Oa u
Signature of Applicant Date
<�at
y m�
All roof coverings to be Class "B" or better
Owner or aothnnaed agent Date
OFFICE