01020076 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: '
BUILDING ADDRESS: • PERMIT NO.
s
OWNER - APPLICATION SUB DATE
SII PHONE: SANITARY NO. CONTROL NO.
00 ARCHITEC'I'IBNGINITIL. Z - IIUILUINC,PI3RM11'INPO
7 REDO CLECIPLUMB - MECH
S vLICENSED CONTRACTOR'S DECLARATION
p 1 herehr affir h t 1 loo I I he[)a do p n' f Chapter m 9(cunen.inJob Description
g -
iSet anO fD - na lthe lh .. dPnf.. - Cde,and my Rcmc
6Y5� ';m r.fail for. J efleet
O ceoSd CI Lo,#sem, - WINDOW REPLACEMENT
Ne.ne J - ARC1111'IiCi"S UECLARA'1'1(1N
I "ia Jshall
.. '
d y plans.h II he u J p bl rd.
S$30 Licensed pf:. Y
c_a, OWNER BUII DCR DECLARATION
I he by firm that I Pt from
the
Corrector's ....e Low,fn the
toll a (Section]03158 . . dl f: Code
Any n puny
u� m was b y )i t II f e l".I I any a Liu i
C prior to a,heir eauata e..Imm to the
m,Cionamm+ii lnl lea.IgoeCha nem • ��•
d 5� (comate licensedpmsumda+ihepmDivisi ninece businesl.,EdProLiwtan,Code) S Ft. Floor Area
(commencing a empt Bowman
n and t e bails o t the alleged
x and RofAny% Calc) 9 r a anon '
of thatheis exempt thacfmm and the arils for the allege)ucmpnt to Any violation -
nf Section II171.S by any applicant tor o permit subjects me applicant to a civil penalty
of not more man five hundred emfara lssren. APN Number Occupancy ype '
'Ol,as owner of thePmpcny.or my cntpinyces witM1 wugcx'aa their sole c0mpenantlun. -
will do BE,work,and the ancone is not Intended•er oflered for sale(Sea 9044. .a
' BaainaA:md Pmfti,lons Code:'Tlm Conoarmr's Liven..Law does not apply to as Kequired Inspections
owner of property who builds o,impnives theater,and who does...a work himself -
m through his near employe..,provided that such improvements arc not intended or
offered for sale.If.however the building or impmvemenr i.s.sold within one year of 101 — ,FOUNDATION
completion,die owner-mtuder xm have the burden of moving that he did not buildor 102 — PIERS
Improve pon,ses,
I l P p ly i I ly it till T v n i 10W a — UFER
t at Pastille,la 9044Bmiars,End P i; )The c Bt 104 —.-REBAR
Lice Law docs not apply to a,owner of property who builds r r improves thereon '
and who anaracto for such projects with a rontracnn(s)licensed pursuant to the
Counselors License Lwor 105 — ANCHOR BOLTS .
O l am exempt undvySec. B&p C for this mama 106 — SEWER R WATER .
Owner
w/nRl<hR'scamr skrloNnl:cl.nl+AnoN -. 202 — UNDERFLOOR PLUMBING
203 UNDERFLOOR MECHRNIC:AL"
1 hcidhy an!...I under peony el'porjury one of the miNaving dsclamtin tv -
• ❑ 1 have and will maintain a Cmifewe of Consent no.elf-i...A far Workers 204 — UNDERFLOOR FRAME
Cemp,mmiun, as provided for by Set 3]W of me Labor Code, for the 205, —' UNDERFLOOR INSULATION
perfurmanm of the work fur which this permit is issued. ,
❑I have:md will nmimmewmIc's Compensation ma,rdn.a:isre 301 — ROUGH PLUMBING a '
puna ywreanys..foo 302 TUB R OR' SHOWER
3700.' the Luhur Cnda,for me Iearunoaoec of the work for which thie pmnnit is -
Carae:My wmkera comren.adon m.aolicy center.,Ed Policy mmmnm 303 = ROUGH MECHANICAL ;
carri.r: - policy IO: - 304 — ROUGH'•ELECTRICAL
CERTIFICATION EN ATiON INS FROM WORKER."
COMPENSATION INSURANCE '
305 — FRAME
Coria vacuum need a.,be compleace it he p.rmit in for nee hundred dollar." - 306 .HOEDOWNS
($lnmorlaaa,l
1 amry thin in the perfonnamr i+r the wank for wmcli d,iaI,�ndt is I.naed,l 307 — INSULATION
shall no,employ any person in any mmmer,m as m fiaxunm subject m the Workers
Compensation Louis of California,Date - 308 '— SHEETROCK
Apphrmt -
NOTICETOAPPLICANT If.ane,anking this Cariftemeof E..cranm, no should 309 — EXTERIOR LATH
become subject the Workermv
Worker's Compensation pisiuns or the Labor Code,you,lost
O C m fmhwencomplysoithsuch provisions nothispermiishot Ibedctared'rev oked - 310 — INTERIOR .LATH
'> CONST RUCTION LENDING AGENCY ,. 311. = SCRATCH 'COAT" '
Inearby amon ton here is:,.nnstmrtianlending agemyfor)at parfinauric`
of the work for which this permit is Iswed(See.3097•Civ.C.) 31.3 ROOF NAIL
;D c icde`riAAddress 501 FINAL ELECTRICAL ENERGY
� z '
U O IcanlrythotIhaveroad'hisapplicationanda,aetmm�ien we information i. 502 — FINAL PLUMBING ENERGY
w F �n t.l nsrtt to romply will,an.nr nml rnnnty ora,larval and acla hwa re•Iniin,
to hand503 — FINAL MECHAN I CAC-ENERGY
ling.00a,n'linn,nnd hereby on a i,a mpraseno(wfihii
er o ,city In elder Lipson - r -
me shove-mtminaedpmperty forim,p.cronpappose,. 504 — FINAL BUILDING ENERGY ,
Ea 0. (WEE,)El mote.,indemnify and keep harmless the City of Cupertino against
toPM
gin.nt...osls and eapen.an which may in any way income against sail 505 — FINAL ELECTRICAL
quence of the gromin,of'his permit.
UNDF 'TANDS AND WILL COMPLY WITH ALL NON-POINT Z--I�-
c+ nor+.. Issdedb 506 — GAS TEST Date
ih.ILA ARDOU�u actor NI Date Re-roofs 508 - "'FI19AL MECHANICALIIALAform t Mdin, I -put SCLOSURHt arrfrant or metre napping ie.opam store m handle naaaraona tmnmal Type of Root
as defined by the Cutworms Municipal Clicks Chapter 9.12, all Ore Health uad Safety 509 — FINAL GRADE. .
Grde.Sectien 25532to1'! -
11 Yea - ON. All roofs shall be iits Fs,eted ppffc�flfs'0hnyFP'bAy��R},1`T4�i�l(9'a�lpbeing installed.
Will the applicant nr fmure building,mcapant useelaillocrit or device.which If a roof is in Stalleff ❑bout tF,1k hiniRAJ3R-itWccWdflaS�<I�ree to remove
ami,heaardous air roataminonts as dofired by the Bay Are,,Air Quality Managmmm�
Dias,,? all new materials for inspection. App 1lcanqunderstands and will comply with `I
❑Yes ED NE,
all non-point,source regulations.
1 have read the hmmduus materials requirements undo,Chapter 6.95 of the
California Health h Safety Code.Sections 25505,25533 and 35574.1 understand that "
if die building dies not currently have a tenant.that it is my rearymsihility to notify the r '
Ore.occupant of the no are, ns which must be met polar to issucacc of a Certifiable nl
^v/ Signaaire of.Applictlnt .Dat
too a oath Tedd E agenDmAll roof coverings to be Class "B"or better
OFFICE