02080088 (2) CITY OF CUPERTINO -
suu.DlNs DIVISION PAIT . CONTRACTOR INFO TION:
Bltd ADDRIS - - - PERMIT NO. - --
- ' '111 C�INYON 'OAK WY 02080088 '
APPLICATION�u..B DA7._
GROUP-----... . _.. ...__ .- .._... ......... . ..._. .- __. ._. .__. -. ._._.08/ 15/ 2002._ - _.
- 1 PHONE: SANITARY NO. CONTROL NO.
Oat o zARCHITECT/ENGINEER: a BUILDING PERMIT INFO
h'U 2 - BLDG ELECT PLUMB MECH
y= LICENSED CONTRACTOR'S DECLARATION Jib D
o z y E I hemby ofrum Nm 1 am liad mtd
nmcr provisions of Chapter 9 fmeo
cmnoing R EV T q T ON OVER TRU?ascription
F,Fw wim S«tioneOWI f Division3of me Business ane RofexsinnsCode,and mylicense
aq ummuforce and oHen IN HOUSE USE ONLY-- (ORIGINAL #01010053)
-s as a license elms i ,lie.x
a i O Date Co..mcmr <7
in ARCHITECT'S DECLARATION
1 undersand my plans shall be vied as public meads
9ag!!t i . . 1. t
a-per L JP fe. ' I S -
S„ OWNER BUILDER DECLARATION
uI 1 it am NRut I rap from the Contractor's License Law for Me
C?a
following a o.(Section 7031.5 Business anJ Pr.fiswi.m,Cod A y city no county
E S�0 which requires a permit to construct.alter p demolish or repo r any swcmre _ _ -
3 m pnor......coca also mquims Ne applicant for such pemdt to than signed statement. . - - . . . .. 4 4'566--.-.----
Nat he isl«nsN pukuant to do Pmviabam or Ne Corrunicus,License Law(Clutter 9 S Ft- Floor.Area Valuation
(Co. Moe .ms«t 701pj rot -non3arNeBustn a dP re stony code). ( (➢t+, i 7T \<q,. j f 'g'�f g,a
or tit tM1enexempt NTcfrooi and the basis for the alleged pt n.Any violation 3425.9007 .'00 - - - -of Section 9031:5 by any applicant for apermt subjects the applicant m a civil Penalty-
of notrnorcthan n,Five hundred dollars(SSWj. ' APN Number • Occupancy Type
,., ol.asowner ofineproperty,ormyemployees' 101 :FOUNDATION-
will
wages chemist Ne r sole to es. ton' - -
' ..wurdo Ne rof wuo s evvnure is Contractor's
o r mmndea o'eLawfar snot(S« 7o an 102 - PIERS: Inspections' :..•. ,. '
ow ,part'Who bi Cade The Co vacs e s. nu law Goes not apply m an Required
awndofhis ow Who buJds.ptmided t Neuron,and ve does work himself or '_" _ .___.._._. -. -.. . .. .-
103:_:'-" UFER
orthroughol pIY eb provided Nts ri improvements rent ¢dJ do _ ... - -._... ... .. _ .
completion.
sI 'Ifm "Nelhavet proofmov -wW midmayear ildof '104'" =- REAR' "-
cmpplffa %c�ucfbuJde ill have the Wide.ot pmvingN thedid ma build or 105 - ANCHOR BOLTS
-m,k.Jlicensed SEWER...& 'WATER _-..- . -:'
td1 a ofthe propc.7 aura«las ly t i g tbcontractors r's
construct m p ,n (Sec 76W Braine d e f ss ons Cade)The Contractor's
s1. 2 0 2 - UNDERFLOOR PLUMBING t
License Lzwdom not apply taan ivies-owner opcoomm-nv who buldsanmprovesws Nam the .203 ...-.. UNDERFLOOR-:.MECHANICAL
,and who.contracrs foaswh.pmj«ts with a mmranor(xl.ucenxd.pmsvant.m the
-
203 c Licence Law.,
01 .
amesemptunJerSec.' ;B&PC for this reason 204 UNDERFLOOR-FRAME,'' ,
Owne, 'Dam - 205' - UNDERFLOOR INSULATION
'WORKER'S COMPENSATION DECLARATION 301 - ROUGH PLUMBING
- - lnerebyaffirmuodetpeaunyorperj.7 aeonnefeuowingdcelausunns: 302 - TUB & OR SHOWER -
,.r.: - -
` , ❑ 1 rave and will aintain a[mihcbte of Consent to self-imum for Worker's 303 - .ROUGH MECHANICAL
Compensation, as;pmrided for by Section 37M of the Labor Cada for the 304 - ROUGH ELECTRICAL
l crfommuce of the work for which Nmi
is pert is issued.
❑1 have'and'"ill=moan workers cmnpematlon Insurance,as required by Section 305 - FRAME
-
37M of be tabor Cade,for the performance of the work for which Nis permit is -306 . - HOLDOWNS
I es J My W k s C pen ro Insurance carder and Policy ber arc' ,. .. .
e r policy
30TH = INSULATIONr` . :.
Came i t • 4 E Pol "I
i t.CERTIFlCATIONOF, ATIONT1ONFROMWORKERS ♦ ti.�� i3O8 I ,':tSHEETROCK I [t)R.
coMPENsnnor{,Iry¢uRArvCe _. 309------EXT-ER-TOR -LATH.'___.___
fThtssacsonnecJnmb<comPIal fNepermitisforonehundredcianars 310 `�-".INTERIOR LATH -.__ . ----
isIWI 1 ', ... 311 _ -.SCRATCH...COAT
.
,( omit pef ftl kf 'h hth
'hall at empl pl r hY personany ?n t becomesubject m me w kJ l .. -. 313- _.ROOF, NAIL"' ;'-
' Cons, tion laws of California.Date -
Applcant. 501___ FINAL ELECTRICAL ENERGY
_...
•NOTICE TO APPLICANT If nmakingm curet ar Exempnaayou.yo nnwd 502 - FINAL PLUMBING ENERGY '
be rte bj' n'meW ke C open-t p shall rhe tabor Cale.you must
OZ _ provisions farm, hall _ _503 -_ FINAL _MECHANICAL ENERGY
forthwith comply with. h cions or Ns
F„ co ns TRUCTIONLENDINGAGENCY 504 - FINAL BUILDING ENERGY" ;
a,> or by hihNtN tura dngagency for m p emanue 505 - FINAL ELECTRICAL '
..r nnne work for which N permli is issued fSee 309],Civ.C.1 .
LeodersAame-._._ .._.._. _ _ _. -506- =' GAS TEST - - -
Z) z se iAad 507 - FINAL PLUMBING "
V`O l saint fy 1c h his ou , atthat a ove information is 5 INAL MECHANICALcbrtecI gree 10 comply 'N II city and counts,ordinances and state refining / V
V
O;U tobuilding construction.and he by authanicmprcsemauvcsofthiscitytoenterupon 5 IW 9' - INAL DE
}'sir] he above-mentioned pmpeny for inspection pm,mes.
Fe C. j agree a indemnity andk ph mows tnect of penin.58nimt 5 - INAL '
h liabilities,judg nt%con d expense which may in any y c< against said 514 A RKS
U:Z City osmo nee of the g ting of Permit,
APPLICAN r UNDERSTANDS AND WILL COMPLY WITH ALL NON.POIW
SOURCE REGULATIONS: ;i„ Issued�� - Dale
Signal of Applacam/Convact Data Re-roo pHAZARDOUS MATERIALS DISCLOSURE
VII m pylic f t rc WIdi g..Fort sone or handle hazeNous.,ad.] . o _
RO -,IN-PROGRESS*
S*
TypeO of ,
as J f d by the Cupertino Municipal Code.Chapter 9.12.and dre Health and Safety r _
-' � - •"
Cad Sectio'25532(al ,
❑No
❑Ye ` � 1•s t. q, - ht 't�i , i,ll�':
All roofs shall be 3nspected.prior to any roofing material being installed
till thecomas applicant or mture building he BayAeamomental tdevices
Management men If a roof is installed without first obtaining an inspection;'%I agree"to remove
emu harartlous air contaminants as defined by the Bay Arca Air Quality Management
Dun?. _ .. ,tt... . ...:_ all
❑Y - ❑N new materials for inspection Applicant understands and will comply with
all non-point source regulations ., .-
1 have read a read hat J `material,mgwrcmems maker Chapter 6.95 of Ne. - -- - -
mi.Health&Safety Code,Sections 25505.25533 and 25534.1 understand that -
iftheWildingdoesmacamemtyhave.tenant that it is my e,,.,ibili,y m notify the --
occupant of the requirements which must be met prior a issuance of a Certificate of ^ '+
Signature of Applicant
a . ... Date
Owner oraaNa and.,at Data All roof coverings to be Class "B" or better '
_<
�, '... .. . _._ ..... -- - -.• ... - OFFICE. ._... -