01010031 (2) CITY OF CUPERTINO
Duu,DING Dtvtsto" PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT'NO.
22241 NC CLELLAN RD CUPERTINO CITY OF 01010031
NER'S NAMI7: APPI.ICAI'ION SUH DATI!
CUPERTINO CITY OF 01/08/2001
'HONE: SANITARY NO. CONTROI,NO.
p z Z AHCIII'1 F.CI'/IiNGIN1i1iR; BUILD 'P13R_I MIT INFO
O O 1 BLDG ELF: PLUMB MRCII
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SNi fou tht[a CONnsed under p DECLARATION Job Description
ZZm hen'hy(hol ,hatlonul0u,dunderpnwi nlirchaptervUanne ing
° wiel seernn 7tx)n)dnTvi.inv3drdle Ba,iaes.11,m rn�r�..icll,ales add,�yia��ll,e
is in fall force andeBcct" REPLACE ELECTRIC METER AND PANEL
c < License Class Lw.x
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Data Contractor
H ARCHITISGF'S DECLARATION
I understand Illy plane shall he load as pnhlin firm..,,
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ce$$ fe
per
p p Licensed Prossional
OWNER-BUILDER DECLARATION
w r'LL I hereby effind Illal 1 a 1,11,11 frndr the CI (n,or'.s License I.:Iw for the
t Z a billowing reason.Isecti...1 90315Business and Pmfe,dons Code:Any city or county2 am which require%a permil In construct.altar,improve,demolish.at repair any stmcium
i
3- prior e ua o its issuancalso requires the applicant for such permit file a signed statement
that haia haled pa....a1nmthepmvislons III tire Contractor%Liacla[,me(Chapter 9 Sq. Ft. Floor Area Valuation
(mmmencing wish Seelinn 7000)ofDivision alit the Business and Pndessions Code)
or That he is exempt therefrom and the basis ha the alleged exemption.Any viclminn 1
of Section 71131.5 by any applicant for a permit subjects the applicant to o civil penalty
or del mora him five hmdred dollars(E500) A PN Number Occupancy Type
❑I.aecr of the pr'gwrly,a Illy nmphwad with wal,c—,thdreo&a,mpenenum, 35706014. 00
will do thcworA,mal the ideal i,nm intended an altered for sale(Sec 70,14.
amines%add Prom,,ion,Ode:TTe Ca drachu,License Law does ail apply or an Required Inspections
,itoof property Who builds o r m,1mthereon,and who laws such work himself
n`n,11g1,1d.awl a,Igdoy�.� ved mm wish an......tepm run, am Ill ialeded or 304 — ROUGH ELECTRICAL
offered far .In.If,howcvee the building or improvement i,slid within nnc ycar of
completion.the owner-builder will have the human ofproving that he did not huilA or 501 — FINAL ELECTRICAL ENERGY
torpnlve but purpose o1 sale). 505 — FINAL ELECTRICAL
❑I,n%nine,el III n......ady.a111 exelusivdy cnoui'lu"with ucenwd c..ne..on,,u
Ldatmct the project(See.70,14.Business and Profession,Ode:)TTe Contractor'%
icense,Law does not apply to an awnet of property who build,or improves thereon,
and who contracts for such projects with a contmctudO licensed pursuant in the
Conaacmh 1.'sn.c Law. 1
❑laid cxcnlpt under See .lik PClinthis naso
0wnrr Data
WORKICR'S COMPENSATION DF;CLARKI'ION
I Mreby a ont out pmlly of perjury one of the diq Hawing declaration.: t
1
0Ot o I 'h d 11 da t Certificate Cons
f Consent nE1 e f Worker's
o
,i H m J 1 by Sect f the lab f
Code, for me
,w,f mince ifII ..it to,whichthis period d ^
❑1 have and will mainnin Worker s Couriptamation Insurance. req mil by Saturn 1/ /
3700 of the Lubar Code,for the perlemladen of the work for which this perfmt i%
need.My Worker,Cmnpensm'm I Inomm,a currier and Pulley mmrnber am:
Carded Policy Nn.:
CERTIFICA'I'[ON Oil Ex Eb11'DON PROM WORKERS'
COMPENSATION INSURANCE - -
This section need not be conlplem d if the permit is for one hundred dollars
I$KXB or Ices.)
I evil,that In the Pset nnnence of thn work for which This ec nil rz issued,1
shall dol employ any9 CiCadd In any atanner nn as m hrannm subject m the WnrAcrx'
Compcn,ation laws of lifornia.Date
Applicant
NOome subj'10 ct in the Wurk If.Cour isrowfg this Ccd11.11111 nl Exmnptinn.You should
hemnr,ubjmJy the Workdr's visions or
nworritmn ofine Ldua Cude,you muFt
Q � limhwilb comply with.uch previsions er Ihi%permit shall be JcmneJ revoked.
Fh CONSTRUCTION LENDING AGENCY
a ; 1 heahy atlien,hal,here is n.....tmelin I lending agency for the peIf..dianec
..I,he work lira which dr%permit is issued(See.30)7.Clv.C.)
6. Q Lcnibel%Name
Q z Lcndar's Address
U 0 H e,rlily that I have read thb apPhrminn,Ind state Ihnt the uhnsc Infonmulon is -
hL E. concert.1 agree to cluninly with all city and manly ordinances and%tate laws relining
rubuilding _I ra ifi mdhereby' th 1 : I Ism (Itis city to mr rym
} thealwWorearlioned property for in%imenner purpose.
ty Cl, rW) yrdb....a.inalconnity andwave b I:.theCty fC Inn ngum
rC0) H'abilf sJ Ig h I,a I no,ranse,whichY in any a,I 'g-na:aid .mss
U z City incmaquence of the grannng of this..earn 1.
ASOURCE REGULATIONS,PPLICANT UNDERSCANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 'ddN
Signature ill ApFlicantlContmcmr Dam Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or froure building«rupant,tore,or handle ha drums,ruamdal Type of Roof
as def neA by the Ce,sal no Muntcipil Code.Chapter 9.12,and the Health and Sleety
CnJe,Swtiun 25532(n)'l
C)'Is 11No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant orfuture building orcepantuse equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
nth haevNnu,air Condoninents as de incl by the Bay Arra Air Quality Miela'a nem
District' all new materials for inspection. Applicant understands and will comply with
0Yes ElNo all non-point source regulations.
have reed the cryCode,
o e,Suctionsdis
regaiRmmnl,under Chapter i dr esea..I the
Calf fnmiuJ lculmhFafory Ctxle,Salinns 155115.2,559.1 and 1551J.1 dymoand,hat
if the building Jinn nal currently tr ve a mama,thus it i.my rencerve Mllty m ilio,the
awcupa // c indlcnu whiab onset he amt prior m issuance of a Ccnificmc of
He IrkJ� —� ^
Signature of Applicant Date
%.def oraumemedagent Data All roof coverings to be Class "B"or better
OFFICE