02070008 (2) CIBUDF6oPvsoNO
ILNiiNPERMIT CONTRACTOR INFORMATION:
16T'/afDRRACIFICA DR PERMIT 62070008
MMMCK JANE V APPLICA0171101AN 0 0 2
PHONE: SANITARY NO. CONTROL NO.
O ZZ ARCIETEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MF,CH
Had - r..0 O L-:1 L_1
�v= ATION
I haiebyafortLICENSED am lianxe undergo o�Ao 0aper9lcommencing ADD 104 SQ. FT, Job Description
=�G with Semion]fx10)of Division3 of the BusinessanJ Professmna Code.indmylimme
m y is in full force and effect.
O i U License Class Lic.a
Dam Carl.,., -�
aO ARCHITECT'S DECLARATION ---1
3 I undersmnd my plans shall he uaJ as public records t
i? need Pmfesxionnl
a OWNER5BUILDF,R DECLARATION
I hereby tuhmm tbar I am exempt from the Convenor's License Law for the 4 0 f 0 0
a,?<
following reasna emiot ]03L5,Business and Professions Co de:Any city or county
F F O which requires a pest.no construct.sites improve,demolish, file O,ir any structure1. _ /(J�
a. poor s,h` is annual a,alsarcquires thovisio firssf,hc uch Contractors imme, ow(Chrued mment
- (commeningwitpSection7")ofDiiision3hftheBacmrsLindProsw(nage)apter 9 r atT,11 s�.-, Valuation
Or that a is ci ens Section om and
Division 3 of the Business and Professions Code) . + i p y ' ,'i 1 -i- ,
ar that he is exempt therefrom and the basis for alleged eRcmgi6d Any violation � - "
of net norm hum bye andledicamrs(SS ). mbjcetxtheapplicanuoe civil penalty p yTyp
of net mare than ave nanarea aanars(SSW). 102A� PIERS Occupancy e
°1,as rsvnen of the Property,ur my employees with wages ns their sole compensation,
will do the workTand the stmnure'is not intended or opened for sale Istt.7344;Th ' — ZER
Required Inspections
Business and Professions Code: e Contractors License Law does not apply to an 104 - RE
owner of property Who builds or impthereon,roves the ,and who does such work himself
or through his own employees,provided that such improvements arc not intruded or 105 - ANCHOR BOLTS
,offered for sale.If.however,the building or improvemem is said within one year of
completion,the owner-builder will have the burden of proving that he did not build or 106 - SEWER & WATER .t
copra for Purpose of sale.). 202 - UNDERFLOOR PLUMBING
as nen projecto propeuyam"elusively and Praenngwnhoeenxw oantanarsm- 203 - UNDERFLOOR MECHANICAL +
License
the ttt(Sec.7044,Business and ony who
Cade)The improves
trareon,
construct se Law noes not apply to an owner o(property who builds or improves thereon 204 - UNDERFLOOR FRAME
.and who contracts for such projcna.with a conwnnr(s)licensed pursuant to the ..
cnntractnra License L.w. 205 - UNDERFLOORS INSULATION
❑ ant ,ansae./ a�Per ni reason 301 - ROUGH PLUMBING
WORKE'SC MPk-' �1CnoNDECLARAnoN 302 - TUB & OR SHOWER
1 hereby afrrm anderpenalty of perjgry not of the f+dlowiag declaration,: 303 - ROUGH MECHANICAL
0 1 have and will maintain a Cenificate of Consent to self-insure for Worker's 304 - ROUGH ELECTRICAL
K, ✓ Cnmperammn, as provided far by Section 3703 of the Labor Care, for the 305 - FRAME
performance of the work for which this permit is issued.
306 - HOLDOWNS
01 have and will'maintain Worker's Compensation Insurance,as required by Section 307 - INSULATION
3700 of the Luloor Code,for the performance of the work for which this permit is
issued.My Wormes Compensation Insurance carrier and Policy number arc: 308 - SHEETROCK
'PaheyNo.o 309 EXTERIOR LATH' -
CERTIFICATION OFEXEMPTION FROM,WORKFRS'I I.
COMPENSATION INSURANCE .. . - '3.,10__.__INTERIOR. LATH_._
(This,actioa need not he completed if the permit is for one hundred dollars 311' SCRATCH COAT
fsloo)ar teas.) 313 - ROOF NAIL
1 certify that in the performance of the work f r wch this Permit 6 muedi I 501 - FINAL ELECTRICAL ENERGY - -
ahall'not employ any person in un ncr so Sect to the Workers'
cnmpn.,dn a �� '�n 502 - FINAL PLUMBING 'ENERGY
AP Ilaan "-_
N 0APP ICANT: Lot ace to of Fit-Pl.you should 503 - FINAL MECHANICAL ENERGY - -
z been aubjecnotheWorker'ICompensationprovisionsoftheLaborCodeyou..at 504 - FINAL BUILDING ENERGY
Q Q forthwith comply with such provisions or this permit shall be deemed rewkal,
CONSTRUCTION LENDING AGENCY 505 - FINAL ELECTRICAL-
a I hereby affirm that there is a construction lending agency for the perfo+mance 506 - GAS TEST
a(ther'sNamfar w `rotaI- . isiaaaee(stt:3o9],cm.c.l 507 -- FINAL PLUMBING
W.. of
Lenders Ne me _, Permit. _ . .. - -. - . . .
O Lehdei's Addicss t. 508 FINAL MECHANICAL
1 certify mat 1 have read this application and amte thauhe above information is 509 - FINAL GRADE
W E;y o6heci.I agree to,comply with all city and county ordinances andstem laws relating
C U 1.buildingconsvuctibn,andherebyamhorimnprooduativesofthiscitytoenterupon 510 - FINAL PLANNING
r� the above-mentioned Property for impacts.purpoaee.
y (We)egreetosave,indemnifyandkeepharmlesstheCityofCupertinoagainst 514 -
FINAL PUBLIC WORKS
ZI liabilities,jorgments,costa and expenses which may in any any rase against said
V Z City in consequence of the granting of this Permit. I., 1'
AP ,]CANT I'ND R T 54th ILC COMPLY WITH ALL NO' )IN
so a Issued by: Date
ams of ApphconJComanorJ ; y+,� 1 Re-roofs '
HAZARDOUS MATERIALS DISCLOSURE
"Will the applicant or future building occupant store or handle haiandcus..,coal Type of Roof
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety '
C6de,Secb.n;25532(.)? .:t•. .1 ' 1 ' ' . .t+ )• ,� s. .
°Ye + All roofs,shall be-inspected prior.to.any roofing.material being installed. ,-
wtn m epplic t f^wrebuildingoccupant use in ipro ntordeviceswhich If a roof is installed without first obtaining an inspection, I agree to remove
mthsourm cum
os ca nasdefmd by the Bay Area AAilQualty Management
District,
eeall new materials for inspection. Applicant understands and will comply with
byX all non-point source regulations.
� � 1 have mad the hazardous materials requirements under Chapter 6.95 of the
if the iHealth s Safety Code,Sechave
ate tenant,?hat
t itis and 25534.1 undersand that r / D
fthebuilding,ha mrnotmuln,currently It No real prior myresponsi.f.Canotify the flJ��O/`/I
ocwpant of the mquimmems which mus be ter prior,.m issuance of a Cc ifc m of �' r��L
OccuPanc tI -
'E(,�_ Ignature of Applicant Date
Ownerorauthoraed Agent am All roof coverings to be Class"B" or better
OFFICE -