01020032 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS, Pr:RM1'1'NO, 01020032
22150 WALLACE DR
OWNER'S NAME: APPLICAI ION..tc�KrD6/2001
BLOOM G E AND JANE E
PHONE: SANITARY NO. COMIROLNO.
=-O o ARCHITECT/IiNGINHER: BUILDING PERMIT INTO
— Ii1.D' LLIiCT PLUSES MECH
¢Y J 1-
Baa
o SN< LICENSED CONTRACTOR'S UECLARA'l ION
n o 1 hereby at that I at„licensee ander nroeidonOil'Charter')(e nuer,ing Job Description
=tw witnsuaion7(xxnlftr m3ofinentlane>,ayll•rnZi �e.xodntyucen„ REMODEL FIRE DAMAGE AND REROOF
n rilam<andcnIyp�sl� . Y
cl,:Clan, Y� Lic.M
+FFq$a Ulm Commc�—
�3a a AAZJI'ItiCP'SDI3CLAR.�ION
nWa,tund nl loan hu ed as pu lac rc ad,
p y Gam/
u a❑'p LicenwJ Pndesional
is.D,o LL OW NIiRr HIJII :in nBthe Contractors
o 'ION
1 hereby.(lien that 1 ten c,anpt from tl,n Ctintmo Cas,An,I ,w far tha
t=c) which
Itninvanu,reason.(Sec n Tql 5,Il, and 11 or,dr ro Code:Any vary a Duty
E p which regain°a TCm,i1 to uun,tmcr,Ding in,provo,AcmalisM1,or repair any structure
W
30 prior to t issuance, l,revire.theapplicantl hren M 'g d:tt nen
'hal lie is licensed p . tl the I fn c nal -1 Lar.(Clrpmr9 S Ft. Floor V k''3QIfi00
(cammLngwith Section 7000)or Division i of the Bu,ine„and Pone"ions Code) tl' 2
or that he is rump,themfmm and the I...is tot the alleyN c,emp ...i,Any viol,non
of Scot 17031,5 by anyuppliWet Ib..penult,cbj,,,s the applicant to,civil penally
of not more than five hundred dollar.($500). A PN Number Occupancy Type
❑Lar ownunit the popery,or any employer,with wage,as theinole cum,ruse ion..
32600032. @@
will do the work. d the li r t r drl or Ormond 1 (See.7(HR.
B ,m di r. cid n c tr t I' 1 d r mly ,,i Required Ins ections
t p p o an n or,rover'h ted n k himself 101 — FOUNDAT q
Or over"
through n. nIy provided rb, n { t t' t Joof /"1
offered],it al. ¢how.c,lb.b Id ny, npr stn.n', IGwn,n n..yild tit 102 — PIERS
completion,me owner-ntliMer will have the wrden of rro.ing that he did not I,uOd or
improve for purpose of side.). 103 — UFER JAN 0 7 2002
I.a,Owner(if the nn,rorty.lne.alussely contracting with licensed contractor.to 104 - REBAR
consumer the project(Sec.7(p4,Bu.inecs and Iaotes,ir s Coda) rhe Cunu xomr's T�
law dne,n,t apply toanowncrof proproy w his liuddso,inios.,'herson. 105 — ANCHOR Bl�u,,a�iWkDING
Ind who contract%for such project,with a contmcmn,)licensed pursuant In the 1 @6 — SEWER R' Ri
Cmanems,License Lary.
❑I nn c.mnp unde,See. .B x P C for Ill,reva. 2202 — UNDERFLOOR PLUMBING
Owner WORKER'S COMPENSATION DECfARAr10N 203 — UNDERFLOOR MECHANICAL
Ihereby dorm toiler penally of periny one Of the billow ing declarations: 204 UNDERFLOOR FRAME
1 nage and au maintain. ccrrdmate of colpetil Iti scII........tor worker, 205 — UNDERFLOOR INSULATION
col„lie ou r. as pnvided bur by section 37(10 it the Lahor Code, for the @1 — ROUGH PLUMBING
perhamm�ee of the work for which nn,Tenni,is i.mor. v
❑Ihave rid wnl maintaio Workrr,Conpen.atlan In, .a,m9nimd by Section 302 — TUB & OR SHOWER
37x1ofineLast,Code,netthepero _ • tt l e1d,i.Tc t ROUGH MECHRNICAs
or w Ic, _
,,,"ad,My Wnrk.'.-ruatitu m II, a nn I•ol n, 3@.:,
Carnot: S II--- policy' r,,,: — ' �( (� 304 ROUGH ELECTRICAL
C1i1Cl'IIICAI'ION Oil EXEMPTION FROM WORKERS 3@5 — FRAME
COMPCNSAIION INSURANCE;
(mise mnecJnnlbeLny,lmalir'heparmiii.roronehunemddopar, 306 — HOLDOWNS
mLxnnles.l°III 307 — INSULATION .
I verity mal in the pertoonanccolhe ,,,it for which,his Tcrnit is-ted.l 308 — SHEETROCF.
,hall not emnlo,any Iscrvm in any roamer m as lit become subject to the Worker'
compn,ationLow,01Caliomia.[)am 309 — EXTERIOR LATH
Apd,aau
NOTICE 11)APPLICAN'1':11,after making this Ceniticute of Exemption,you.should 310 — INTERIOR LATH
Q Obe,u ne xubjem m the Wm it,,,Can,pensullnn provisions of the Labor Calc,you donut
lurihe'nhcoanpl)with such pmvi,ion,Orthis peroul haRledeaned,noAcd. 311 — SCRATCH COAT
FCONSTRU(TION LENDING AGENCY 310 — ROOF NAIL
ai1 hereby adi,m that them is a construction Icnding ageaxY ria the perinnnance —
w tiIthelinkllmwhchlIn,fcm,disissuedS,,c30cD.Co.C.) 501 FINAL ELECTRICAL ENERGY
Z” A ender',AmJmss
5@^c — FINRL PLUMBING ENERGY
U O T I vilynre,Ih,,call thi,a,pie.tion:nd,late that he above mfo,n.mmis 503 — FINAL MECHANICAL ENERGY
I.. (• conceit.Iagree roaanplywhhall city and county ordinances and%late lawsmlming 5@4 — FINAL BUILDING ENERGY
Q t.7 n,b .am
udding cnnelion,.,,it M1eohy amhorirc representative,of this city m p
enter upon
m theaswe-mentionedpropenr for inspectionpmpn 505 — FINAL ELECTRICAL
to 6. (Wel agree to save.mdcnnndy and cap hnmless the Cryof CrT:nllat'mlgaina
vh 1.10 litO.,odgmm�,,cool,and c,pcna,word,mum in any way accrue against slid
City incon,ciamceofthegrantingofn,ispemdt. 506 — GAS TEST �_ /
APPLICANT GUI.UNDERSTANDS AND WILL COMPLY Wo TILL ON-MIINr Issued by: S07 — FINAL PLUMBIN$)ate
/\ ' tom of p"onocti ,otil DamRe-roofs
.ARDOUS n fo
MAIFRIA1s DISCLOSURE FINAL GRADE
wage leaor beEJingottupavt$tom ,,handle n,aardo.,InutenW Type of Roof
as der y ore Cupenb,o Monieyad Code.Chapter 9.12,and the Heahh and Sammy 510 — FINAL PLANNING
C c,Section 25532(x)'
oyes 0 N All roofs shall be il5lie4tcd-plFi)INEI Ik3U%TrQteW3lW9t installed.
Will lhe:mPlieanlurfuture toldineoccupxo .,ceripmemofdevn'e,which 11'a roof is installed without first obtaining an inspection, I agree to remove
mmir hazardous air Our n ninums a,dcined by the liar Arc,Air Quality Mwagnnenr,
•amen all new materials for inspection. Applicant understands and will comply with
Ole, ON" all non-point source regulations.
I have read the haaardoux n,:acriuls requirements under Chapter 6.95 of the
Calilbmia Urahs N,Safety Code.Sections 25505,25533 and 25534.1 understand that
if the building does an currently have ulenunl.that 11 is Illy respun'duliry to utility the '
Occupant or the retnairemcm,winto,into,4 mm
hich e,poo, iv,um,«nl v Certificate of
o,,ccu"Ney. Signature of Applicant Date
Owner or authir /9 e All roof coverings to be Class"B•'or better
OFFICE