01030015 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS; PERMIT NO.
10820 SANTA TERESA DR 5
OWNER'S NAME APPLICATION SUB DATE
L PHONE: SANITARY No. CONTROL No.
a-Z ARCHITECAENGINEER: BUILDING PERMIT INTO
00 NLUG IiLECr PLUMB PATCH
LL`
rtzG IJ I--1 I=1 CI
S'�NI.ICENIEDCON"i'RACIOR'S OIiCLARnTION Job Description
I berth,alarm mal I am Bisected male,polkiortnl Chapter 9(commercial
F@!=J 0 7M with SectionVBfgBnf Dieinion 3oflhc Business ane Pautesvion CWr,aadmr licence
rYE� ieir ,llfnree°"fel — 77aySI SHOWER PAN R• PRESSURE BALANCE.
�� IJai na Glu.x_ Conti
O i u Date Cmntmel„�
3 a o, ARCHID CTS DECLARnI'ION
I umerxland nay pJim,shall he used as public record.
ce"y`e 0 Liecoved Prole.vuonal
e d o 0
�C
OWNER-BUILDER from
W I hereby.(See that I n naps from ma Contmmni s License Law f r the
folloitCZQ which
resreams.action
7osnLhLNmino..mprve.&.mnn.Code:Any cryutrarmnty
V. F which regains ii peat,m aasnua."Illi,.impmvr,d:mMish,or repair any a,vnum
$ pnonosxcensed e,rl.v,tequirbenovivonmliars"aunnoto-Licese lawiCalentenl
ma,hei,.Becn.ediSectio It be m•ci. mf ofth,B"siav,,aa,moswtcn::pm," Sq. FL Floor Area Valuation
@°mat he is exempt
thenen om n of a basis i of the Ht ed ev and Pn,fAny%r code)
of that he is exempt Ihercfnm,and the boar.for ct%thJ ra)l cam t.any I rotation ,�
of Section mJ15 by city dallillied oll Ilsr a p<•nnil mAiccd me apPlicam m n civil Mn:Jry -
ornitm.,mmanBvcbnmo-cad,Imr.tasntn. APN Number Occupancy type
ID 1.as owner of the powpi or an,employees with a,c,to her,sole compensation.
will do Im work,and the arao c is on intended c, ,tl,,cd for sola(Sec,7B4, 3961 00
Bnsinc.s and]'ro@..am,Code:'rhe Contractor's License Law dues amt apply m em t equired Inspections
t� r of nropeny Who bullet ,,imposes meteor."al who docs such work himself
rough ms awn eaplmycex.provided that such improvement,are not intended or 202 — UNDERFLOOR PLUMBING
illered lir safe,II',however,the building or imm
provec,n is sole within one yea,of
i°mpletion,the owner-hudder will have the burden of proving that he did neo build or 301. — ROUGH PLUMBING
mprove for purpose mf safe.).
❑L, oxner.,fM1epropcry,amnxebtsmelyeoat„c6r,with llcmacdoulricta,t, It, 502 — FINAL PLUMBING ENERGY
Lnnstet me project(see.70,W.Business and Professions Code:)The Cuntmmo`. 507 — FINAL PLUMB I NG
icense Law dons nor apply to air ommor f progeny who builds or imi hemm,
mJ who contract,for such pmjc,ta with a ,mura,to,D)lwca,,l pur.nam or the
Contractor,Liccme law. -
❑1 am exempt untkr Sec. .B&P C I'.,this rea.mn
Owner Date -
WORKHR'S COMPENSAI]ON DECLARATION
I hcrchy alliom mudcr prnulty of perjury one of the following declaration,
❑ 1 have and rill maintain a Cenificale of foxy, n,w9Ginmrc for Worker sj
Compensation, as provided lin by Section 3700 of the Labor Code, far the
performance of the wotk for which 1h1,perail is i..ovd, 2
❑1 have and will andrain Wo kca's Compensation Immanee,as squired by Section 2/
3700 mf the Labor Code.Gar,he performance of the work for which this prior'r,
iuuef.My Workcr's Conapematinn Insurance carrier and policy number am. O
Cunicr: Policy No.:
OUR I IFICA'I'ION 017 EXEMP'T'ION FROM WORK17KS'
COMPENSATION INSURANCE
(This rn'tion need not be Completed if the Penni'is for one hundred dollars
(SH%y)m le,.a.)
1 verify that in It pert I the Bork far which,his permit i..ned,I
.ball t pIY y' nit h %abject'o the Workers'
Corp f 1' : Lai to.
Appl c t
NO DCl TO API I IC I If. Be king t n f t ,f Exemption,you should
hcnut -b) � t cW k C P an p f 0,L.aNs,Cooly yet nm,
Q ran rbc ) 'itis p nth pr,1.1ll he Jvemo
ed roked
Z C
,^r 0 CONSTRUCf10N LENDING AGENCY .
a ; I hereby anima door Them.,a con.stnmtimn loading agcnsy fur the factonnimc,
tithe work far which his permit i.issued(Sec.30N7.Ci,C.)
C. Q lender'.Name
.7 Z Lcni Addis,,
V O 1 ccmfv that I have mad this application and state that the ab.we information is
W. ate. come'.I agree to comply with all city and county ordinances and.state laws relating
O V IoM 11 it,conqraction,cadI ly calionic repreventativesolf-:cityt tervi'm
} Li:
he ash i J pend 1 Pet ' p D `.%
F„ Y IH ) g t v indemnify and locep huurnflheovala nit
Bi) Idb expsn Inch 'y any way accaccom r u
g' aid
z City in
'.cut l ? )
”. APPLICANrERST 11 LYWITHALLNONPOIN'T a
user cu Issued b � /�A.�� Dale
•Batmen Aar,icimrad... - Dae Re-roofs
HAZARDOUS MAI'IiRIALS DISCLOSURE
I the applinnt or future building occupant store or handle heardous material Type of Roof
red by me Cupertino Municipal Code,Chapter 1).12.ash'he Brehm and Safety
Code,Section 25532(dl:'
0)'°i All roofs shall be inspected prior to any roofing material being installed.
Will tire applicam,it Into,,bmddingoccupant use evuipmem(it feaices which If a roof is installed without first obtaining an inspection, 1 agree to remove
mi
et hearchm,an ci a aain°Yl.u.J•mcd by the flay Arca Air Quality Management
Diadietp all new materials for inspection. Applicant understands and will comply with
El Y” No all non-point source regulations.
1 have read the heard°".momen lv requirements under Chapter 695 of the
Caliliornia Usalh&Safety Code,Seen 1,25585.25533ane53d.I undenwnA that
il'me tuilJing ane,mor can color .Ivncsibilltyw nolily rho
acupamof the rc a 'its whi e,pr osuanac of a Ceni ream d
`y' ._ Signature of Applicant Date
oxeermaamnd, agen� All roof coverings to be Class "B" or better
OFFICE