00090073 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMITCONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
OWNER'S NA2 — APPLICANONSUB DATE
EEN DR souTHBAY CONSTRUCT N
511 DIVISION STREE
PHONE 1 SANITARY NO. CON9ROL NO.
wO O AIICIII'I'EC'1'71SNGINHER: "'' BUILDING PERN1i'I'INFO
z w Ci— BLDG FLECT - PLUMB NIFCII
D
d
Z�y LICGNSIaI CONTRACrOR'ti DECLARATION
m 1 M1erebY vninn,hat 1 am Iimn.wJ under pnrvi,iom of Chap¢r 9(commencing
�_t-w with guctiOn]IXXB of Divi,ionJnf,he Buaine,s send l'rofe„inn,4Code senUd my licentt
a y Y- i,m full hme and ,. 3 r3 G�9 `/
< Lictar f Lic.N J `/
xoaD nate edramen_ TEMPORARY 30 DAY PERMIT
a.�- ARCHITEcr'S DECLARAIIG
macmmaa my pmn.,nau ro a,«1 as puna rermd..
'ser
W ac o uaned Pmre,,aonal '
es t'.1OWNER4lUII.DI?R DECLARAHON
1 hereby n0irm IM1m 1 urn exempt from Ihn Coaeuctnr's 1icetse Law forthe
C>4< r,lluwing,u:non.(genion 70.31,5,Ihdiness and Prafession,Gxle:Any city ser nn,nty
E s❑ which myuirc,u"aril m cnn,lmcl,ober,in v.dc,aolim,ser repair any,Itot„c
a, pd...w a, wium,.k.re,me,the applicant htr such lte,'mil loflca,igned sutcnrenl
,fimheislicensedpm,nan,mmcproo„Ina,ohhdC:anoted",Uen.nww(Chapter9 Sq. Ft. Floor Area Valuation
leonunending with Section 71XMp of Division 30 the Business and Pm(e..inns Cale)
or,hm he is e,cane therefrom and he nasi,far to alleged exemption.Any violmion
al Section 7031.5 by any applicant for it perm,subjects the applicant to civil penalty
of an,,nn re man rise hundred dams IS500) APN NumberOccupancy ype
❑h us owner al tc pmpeny,or my employees with wages os,heir sole compcns.ion.
will do,he work,and the,9vaurr is nm intended or oRererl for sale(Sec.AW. - ,
Business and Professions Codc:The Cunm cmr'u Livers Law doe,not appb n an aired Inspections
owner of properly Who build or improves thereon,and wb6 does such work Wamelf
ser through his own cmployec,.prc,,dcd than such improvements arc no,intended or
olferrd for,we.1f.however,ate building m inlprove,ncnt is,old w,thin one year of 101. — FOUNDATION
L,nplmion.dre twner.nailde.will nave roe burden of prh mg that he did nut build or 102 — PIERS
,t,pmva ka m......n oawo.).
❑I,is owncr at trotparry,,,n caduanely rh„nmetlg widh nenmrd cnmmnor 103 — LIFER
i,nv0nt tc po,co(See 794,limina,,aml rrofa,.io,h,Cotc:)The Cotamcl ` 104 — REPA R
ia,sme L.,doe.urn apply m an owner w'pmpeny whit nand,or hnpmm,merron.
acnI who contracts fur.urn projen,with a tnmrac,ou.)frcmed par,aan,n oto
nmmcmr
❑I and exempt under Sec. .Nk P C for this rcaon 106 — SEWER & WATER
Owner
WORKER'S COMPENSANON DECLARATION 202 — UNDERFLOOR PLUMBING
Ihereby affirm under Penalty ofperjuryone ofthe following declarations 203 — UNDERFLOOR MECHANICAL_
❑ I have and will maintain a Certificate of Content u, .elf-im,are for Worker'. 204 — UNDERFLOOR FRAME
Cmnpen,mion, a, provided for by Section JAX) of to Labor Cwr. or the 205 — UNDERFLOOR INSULATION
perfiamarrre or the work for which this pe.,pi,is is,raaL
❑Imwe:,, Twill mantannwo,kilt,Co„isco,:aInsmanae.a,requlrcd by Section 301. — ROUGH PLUMBING
nun of ate Labor code.ter rbc"bllnmm lir 1,v wok ter which this per i. 302 — TUB & OR SHOWER
,said.My Worker',Camp:u,wiun Ia,ar:ume caviar and Policy numbcram',
303 — ROUGH MECHANICAL
Ci 1'li'yNt:
CERIIFICAT1ON OF EXEMPnuN FROM WORKERS' 304 — -ROUGH ELECTRICAL
COMPENSArION INSURANCE
305 — FRAME
ITM1ix ttnion need nw be complctedif,hc pcnni,i,for one hundred dollars 306 — HOLDOWNS
(SI W)or IcsJ
I ready that in to performance of the work for which this permit i,issued.I 307 — INSULATION
,hall an employ any persam in any tnnner.wt as m necoma subject to to Worker,' 308 — SHEETROCK
Compensation Laws lir California Dam
Applicant
NOI1Cp-TDnprucnNr lr,aver mau,hs tni.cenifie:nr of Eaetnmian.roa.nowd 309 — EXTERIOR LATH
Zectneo,njcttothe Woke.Comptonajonmu,i,ao,t„ofteLuber cude,you tnu„ 310 . INTERIOR LATH
ZO rmtwlm comply van such provision or this pm,dn aural he deelled revoked. •-t
ZCONSTRUCIONLENDmGAGENCY 311 — SCRATCH COAT
I bract,arfmt that thea i,a cunomeaon lending spears,for to permonanco
oF4 oraex,tkbur wldrn,his ,i,issued(See.3tgzON.G.) 3].3 — ROOF NAIL
;D z Leader,Name
501 — FINAL ELECTRICAL ENERGY
U 0 1 cenify that I base mad this application and state that the above information is 502 — FINAL PLUMBING ENERGY
R t.., course.1 agree to comply with all city and county ordinance%and state law's miming 503 — FINAL MECHANICAL ENERGY
G Vto building construction.and hereby aurhorim representative,of this city to enter upon
y W the unwe-mentioned property for Inspection purptt.e,. 504 — FINAL BUILDING ENERG
a (We).,meto,ave.indemnify a ad keep hat mhless the city of C.,dmo against
(n fishBEin.jadgmcau.coo,and expenses which nay in any way sector against said 505 — FINAL ELECT R I CRL
v z City ntancyncnccmbesmntir,ort hispermil. 50Er — GAS TEST
r APPLIC
13 ST NDS AND WILL COMPLY WITH ALL NON- INT Issued by. Date
SOU EGULA S. h 1W12 y'
.Sis,n. nrnpphnne)c urn - p(/ta/'rfLY—/ Re-roofs
1 RDousMn'naR1AlsDISCLGSURE 508 — FINAL MECHANICAL
Will the npl .,h,mmmrr Mdlding ocr„pw,t.mm or banns na,mm ,s,nmcdal 'type of Roof
as defined by tc Cuprnmo Mmuci Code,Cmtptcr 9,12.inch.Health amt safety 509 — FINAL G RADE .
Code,Section 255321a11
0 Ye, Nl All roofs shall being 1ecl�d�r�6�tai-art�Irc �i�ItSi!�ihrial being installed.
Will tcarptiran,arfammbutdingeecapammecquipmemardr,im,xhich II'a roof is install *itlmudfii''.IYIA6taif-riV>t lob f�spbi(rt6ti' 5 gree to remove
snit harmdao,an conmminanr,a� /dcf ned by the nay Ama Air Gua11y lvanasemen,
Di„tic,o If/N all new materials for inspection. Applicant understands and will comply with
Yc
all non-point source regulations.
I have mud,he hacWon materials requinnnem.under Chapter 6.95 of the
California Health&Safety Cale.Section,25505,15533 and 25534.1 undersand that
if,he nuildh does urn currently havea moon,,,hal it i,my responsibility set no,ity,he
cupam nl',hc rrynircmcnw 'rh nnt,l nu amt prim,o i„uanrn of a Ccniticate of
Signature of Applicant Date
D t hod.m agrn, d �� All roof coverings to be Class`•B•'or better
!` OFFICE