00100181 (2) CITY OF CUPERTINO ';.° t
DUILmrvGDlvtstoN -PERMIT CONTRACTOR-1`- F,&MATIONf'�
BUILDING Af % S. - H'st PERMII'NO. >? ,
OWNHR'SN - _ APPLICATID . ISAI i 2 t
SANI'I'ARYNO. - CON'I'ROLNO.
9 p CHITECT(ENGINEER: BUILDING PERMITINVO
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to BLDG ELECT -PLUMB MECII
Nzas 4sc
i LICENSED CON'TRACFORS DECLARATION - ' slob Description.
Oz4a Isembynmm d tI mBttn d 'collo a.ainnsorenapt<r9frnmmeneins
t-ua with Section 701111 o(DI Jnfihe Business rofe
d Formations Code,animy license BATH -REMODEL
yy .J 1,(lit r td clictttJJl...���
C¢ Ivicenu Clgsv Lica M 'r
C3:r Dat </`/'J-� �6— f i t
V,�.. I .rnd my PARC TS DECLARATION Id au,01homenod,
Y
3
tpirEpO LicarwalPrf I
OWNER-BUILDER Iamm1rn R DECLARATION
u� literary R Ihat 1 asempt I th Contral License Law for the -
!-Z a
following reason.(straiten 79315,Bear,and Pndeaions Coca:AnY city 6,county ,
5, ee which I fern t constrict,spar, p J nliit I nay.lo ch'' - • g/
IS5 phi t t: ,ul marines pr applicator 1 permit is . bed stain..'.. 1 s
that he nlicensedlSepursuant m p Dino. fm<Contractors l License t ,ms(Chapterv Sq. FL Floor Area I
(rommcncag vena Section 7a1i inthe hesis lar
the Business ex mp i n,rAiry ve Code)
or mol ani.excnyn Ihmafnnn and the breis lit s be cts the
exemption.to Any viPenr(m
of Section, b n to,,hby undred
llars a N'nnit auhjc'ty the applicant to n Civil pcnolty ,�
ornotattorematron<nnndreadonars(sstnt. - _ ARFk3ffi � ,Occupancy Type
Clif as ownerul'theprolwl ly,oriny. mufflers wall wages as their sole compensation, fry ii'�AL' '
will do the wink,and the'mature is not intended or offered for sale(Sec.7z. 1 1 FIUIIih.Z(li 11•Ukr-'l,apec[ions
Business and Professions Code:The Contractor's License law docs not apply n an r
owner of poultry Who builds or improves Thereon,and who does such work hintsclf
m through his own employees.provide)that such imphovtn¢ms am nm intended or 1,�G' — PIERS ,
offered rte sale.If,however.the huildirig or impramment is sold within one year of
completer,theowrardamicer will have the hordemnfprovu%that he did nal build or 1.03 — UFER. ..
mprouo rohparpmeof''I°'). r .1.134 — REBAR '
❑Lasoven..ofnt<proprr.amex'hai,tlyrontmmmswith licensed mnmraam"o, 1.05 - ANCHOR 'BOLTS
Tconstruct the F Ject(Sea 7ETt,ntlsinesa ane Proles....,.Coxm:)'I he Com asamn'a
aranteLawd„esna apply toaanwn,ofpropmYwho build,orimp rmeadteteoa, 106 SE61ER $ WATER
and whin ountrams for such projects with a contractors)licensed museum In the
Oinm n,est License erLw.
❑mmerc2132, — UNDERFLOOR PLUMBING.
emptunda ,H&PCI'ur thierrnson
Owner. Data 003 — UNDERFLOOR MECHANICAL
i WOR kER S COMPENSATION MLCLARA'I ION - 204 — UNDERFLOOR SFRAME '
Ihereby air,.under penally of perjury to of the buttressing declarations: 205 — UNDERFLOOR INSULATION
r l have and will atf.dmmd a Ceodrate or Come., d,self-ila.mn for workers 301 ROUGH PLUMBING
oonpsamation, its provided mr•by Section 9700 of the Labor Code, for the -
rbmmance of the walk for which tris permit is issued. 302 — TUB R OR SHOWER, '
-1 1 have and will maintain Wurla,'s Cominarratiou Illsomme.as are,porad by Section 303 ' — ROUGH MECHANICAL-.37M .
'I...a of the orkersCom,`far edi performance of the work far which Nis l,rmtit is 304 — 'ROUGH ELECTR I CRI_
ued.Af Workers Crete ovation lnsnnnrc carzier and
�Policy number ore:
cam<r:.$j,�Ptill UtrKC Policy N., �Jl�/ 36 305 - -FRAME '
CEO'IFICACOIPE
COMPEN OF NSATION INSURANCPT ION 14ROME WORKERS' 3136 HOLDOWNS '
(This kerion need ant be amindeted if the p..til i,fair one hundred dollars 307 — INSULATION
al Wtmhss) -308 - 'SHEETROCK .
1 rettiry that in the performance of the work for which this permit is issued.l
.halt not employ tiny peaon in any manner sr,as m become subject to the worker; 309 — EXTERIOR LATH-
npp ,111alronhaw,inrc:duomi:.,Dart 310 — INTERIOR LATH
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should - '
necome.subje't m me workers Condensation provisions of the Labor Code,you:moo 311= — SCRATCH COAT _
O 0 fornwapt ruanlay w,lh.ml,proem is oh Itis panni,ahill ha d,rued rood,l]. . • 313 — ROOF NAIL -
`L .. ,
ti CONSTRUCTION LCNDINGAGENCY
(✓ Iheren aflrmmardemisa"Famtdnnlandin - 501. —' FINAL 'ELECTRICAL 'ENERGY'
v s agency Tor Int pcHoranunee
a y
of he work rnr which this permit ill issued(See.,J1197,CIv.C.) .
w p I.endn'sName 502 — FINRL PI_IJh16IMG ENERGY
Fj C
Leader',Address 503 — FINAL MECHANICAL ENERGY
I certify that l have mad this application and sunt that the aMwc information is 504. — FINAL 'BU II_DI NG' ENERGY '
tr.
.'normal.1 agree t c mpy with u vily and issitum,
onfirmuses add late lawsLog
CTinbuilding armInelon,and h by aulmorim represculativesor city in , upon
05 FINAL ELECTRICAL
(WrOequal,t de 'fy andkeep re the era par ,fast 506 GAS TEST
ho above-inin toll P P
Z) liabilitiesjudgment: c t d M :eswhichna)it any way area ug+,net said
City detccmmebmar,,oln
507 — FINAL PLUMBING
APPLsOURICGkTUND' ANDSgpDWILLCOMPLYWITHALLNON-POINT Issued by: ,�erTA cTh1Al MrEcLT��rt+ri[AI Date
SigrnfrtolAppli'anuCCtratua Data Re-roofs 509 — FINAL GRADE
HAZARDOUS MATERIALS DISCLOSURE
Wit Bar or Non,lwildingm'upanl nm re or handle hazWnus macnal 'Type of Roof 51.0 — FINAL_ PLANNING
rex defined by the Cupaninu Municipal CTula,Chapter o.I^-,and the Health grid Sam,, -
CaaeSertionzssJz(ayr 514 — FINAL PUBLIC WORKS -
0 Yes .All roofs shall be inspected prior to any roofing material being installed.
AOL W
apphranlor raver'nniming ortapa,.,n.<er,nipot<nl oh d<vire.whitn 'If a roof is installed without first obtaining an inspection, l_agree to remove
emit hazardous air ttntnminam,as defined by the Bay Arca Aar Quality Managcn mer
ostia? - - all new materials for inspection. Applicant understands and will comply with
ave, Aver' all non-point source regulations.
1 have real the el tornadoes umtenals rcyuimmemis under Chapter a6.?5nd d the
elifn I hlfeahb ger Safety nade,Santana s requi85n and der C d teulenr:o aha s
f the bdJding does not currently have accrued.that it is my responsibi lily to notify the _
occupant of the requireenmusme
ts which t be t I nr to oeniicate or
oif a C
"all°°`r. mSignaure of Applicant Date
'ali'lanaryr aamarr:'a agent .. nm< All roof coverings to be Class "B" or better a.
• OFFICE