06020067 r"' 0131
ITY OF CUPERTINO BUILDING DIVISION PERMIT COI�TRACTaR INF,ORMATkIO 'mxtil ^Y'� ,K 5-.°LDING ADDRESS: PERMffN0.BUBB RD
NER'S NAME: PERMI'L$T/EDATE
APPLE 1450 VETERANS BLV 04/05/2006
PHONE: SANITARY NO. CONTROL NO.
(650) 474-1450
ARCHIiECr PNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
zZ
uOp LICENSED CONTRACTORS DECLARATION Job Description
1 hco by affirm Nar I am liccnw a p
urJoaiilm aaof Chep.9(comb`g P
with S,slon 70(50).( maion 3o,1'lha Buaincai and Pfofcalftma Cock.and my Banat u REVISIONS-STRUCTURAL/COLUMN/CONCRETE
y in fall fora and elfacL Y99 b •
Lkanaclaa /f /!7 Lk.h LINTEL FOR EXTERIOR DOOR
`sAH�C`rsD�`M A N "d° NO NEW PERMIT-ORIG 05090214
�¢� IuMerv.nJ myPWadNl he tsadu Podia rtuJa
cu.u. Licensed Pn{cuionJ T
O Con
i
OWNER-BUILDER DE TION 5 I herohy.(Iles Nal I un exempt from the Conuxla's I Any
law for the
D following wan.(Section]!131.5.Buvu•=and Prordcoo-] Cole:Any ally or rounry
3_ which jl til o a parson to c .do, alter,impmst,dc.it t,fi .p iz any,ln.Ot
PHuwilicroadpoul mqo Unc Jar applicant for soh trmitwiRaxLw(Cncdl . tnont
££ ° Natn..InvIthS nmm00)OfvW.o3Oplut fthcB.icmr'andPnsclurwsCodc) 9 Sq.FLFloor Area Valuation 0
ERR thamrc a..,th$Non)mod tic vision3o alkinaluu d.Anyn olli.of
��.. that he la emmp Jcmrmm mod or pen it bc.lkgtb a braloto Any violation of
Sttdon]0]I.5 by ant,intrad irdiam permit subjecut Ne.pplicros w a ciWl pesulty of APN Number Occupancy Type
nor mac Jon fiat hvtWmtl dmlaas
❑1,u owner or ft popery,a my amployrrJ with wages m lheh mk=Pewtbn, I
do tic work. Ncavvcwa u not intended or fa,alc(Sec.7044.Buutaca UI e4J Inspections
will
art Pmfu,iocu Codc:'Ibc Conlri,mWs Liccnx Law dorra nor apply N,n owtrr of
pWenywW huiMaalmp�Ilxreaa.Wwlw aou,uch w«tnlm,lrm WwN ha
owv employes.Ptwlded Nsarch imptoa taare ndi andM woferW for.vic If.
bawascr,Ne WItingor hnpmvoemissold within oro)ear ofcornPlcuon.IAC orae- �/y
bulltlawill haat thednd,n of pmNng that k did imt WWW or Impmsc for Ptupoa of I (�kif�R tool]
a .).
❑1.as owner or Ja tc.704..B amara and contracting with liamet mntnzwra i a�s. ��g p�
AN
. ct Law
Ptoje4old,t ..orwn of arAn,who Wild,
orhm1nC themoa',Li" IrpfIIgL��7V[gW■Vt9gep L�YB®�dp{
ameonu tufo fidapplyman owaaorMoOrpl who buildsaImpmrca Nerem,aM
who conuacu for w,M1 pmjecu with a rnntrsotor(aj licetued purevent to the Cmnsxwra
arta law.
Tani uemp under Sec ,Bh PC fa Nta Tamm
ora
Not-
WORKERS
ao,WORKERS COMPENSATION DECLARATION
I ham by arm under pemiry a Perjury One of the following decl"tonc
art❑IN ae arWwillmorby •CCNOam atLabr Codc. rfarWoomoCampen-
wo on,for
ra by Ballon]]00 d the labor,Code.fu tic peRormnta of Jn
wort for which data pvmit H isisN.
1 h.se and will mi Wakes'.Co opcmarian Tnsntri.s regWw by SUJn
31/00 of Ne labor Code.For Jo,perfamanee of the work fa which Nit pvmu u ivued -
My Workera Caniemuim Inwrarac caniv and Policy number tic:
n1A%: L t eij LfLe�Policy No.:W L 11,?D G G .
CE nFICATE OF EXEMPTION MOM WORKERS
COMPENSATIONINSURANCE
Mir ,,d.otcd tot W canplctad if tic permH Is fa one hundrtd dollars 1$l W)
or i...)
I M ify that u tnc pa formartrc of Nc work for wnich Nis parch H Iso d.I Wall sur
cmplay any Permo in any meencr m a to baome mbje<t to Jn Worten'Compev W oat
Law.of Califamle Das
Applicant
NOTICE TO APPLICANT:If..flcc making thus ect ifiule of Eacmptim yes Wuuld
become subjen w lh Wott,ra Compcoalim pm+isions a Ne labor Cade,you muv
OfmnwiN wmPly with suchpovi,fom a this Mini,adult he dsxnmA mwtcE. .
z CONSTRUCTION TENDING AGENCY
[-.— IIewY.Rrm that NemhaattswcJnn WWing.gency for Jr perormana fir
Ik> N,work rat whin Ni.pem,it is mored fs�3orr.cl..c.1
(37 Q Icvdcr',Name '
z lattdch Aad=
U O 1 ccolry Nat I Nsc rtes thla ap,icuion,nd auto,Nar thc.boac Information u
IT,E-n coon.I agra to comply with all Cty a"county cidimuu and nine laws relating w
0U building cotpoction.and hcrchyauthowe rcprocmnivc.or this city to rocr upon the
W whoa-mentioned popery for imPccuon which"a
(Wc).6tra to save,indemnify and keep hamlw Ns City M Cupcnino agairut
IIab111Ju.judgmcnu.cmuand capctws which may in my wayxrncag�nuaaid City
U 7 incon yanaof Nc'p,mmg MNu prnnlL ��;
r^^ APPLICANT UNDERSTANDS AND WI L COMPLY WITH AIS.NON-POINT Issued by: Date
SOURCER INIONS.
-og Re-roofs
garam f ppli.vc 1800 S TERlA13 DISCLOSURE '� Type of Roof
WI..do,arroyo,at ran Btling acupmt ucm ar hartA,hvallom mammal
�trd by Ne Cupetum Mun aryl otc.Clup¢r 9.13.W Jr HuIN sod Safely
-ak,5crfi.n 53z(ap All roofs shall be inspected prior to any roofing material being installed.
Cl Y.
Will tnc applicw or fWum Wilding aaupom tie cyuipmcm or JcWm which If a roof is installed without first obtaining an inspection,I agree to remove
emit barardous air contamimms u denn,d by lbc Bay Amor Air Quality Mmapcmcnt all new materials for inspection.
DiWict1
❑re,
1 hove mad the barardous m urriels mWimmcros umkr Citepncr 695 of the Califor-
nia Health k Safety Cork.Secuora 2 M5,25533 and 15554.1 tndm auN Nat if the Wilding
docs not emre Ito. •o,nane that lt' my rmpomiWItY a notify Nc oasgant of the
myaimm wmnmmrlxmctpnor on"c icor 0oanor. Signature of Applicant Date'
��L All roof coverings to be Class"B" or better
whovcd ,cnr Dao,
CITY OF CUPER INO ' ` *y' = �' �
BUILDING DIVISION PERMIT i.CO�tTRACTQWW0RMATIOIV`` '.
BU DOING ADDRESS: PFAMrf NO.
10131 BUBB RD
R'S NAME: PERMIT LSUE DATE
APPLE 1450 VETERANS BLV 04/05/2006
PHONE: SANITARY NO. CONTROL N0.
(650) 474-1450
ARC13I TECT/ENGINEM: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
30o LICENSED CONTRACTOR'S DECLARATION Job Descri tion
£�
I bacby afRrm that I.m Ilcemcd uMu pmviaoas of ChxI cr 9(cxxm cinj P
NSafi.7")of Divi-m3ofthd Butt and ProfcLi Code,ammynaveu
in bull i-m.ndefrem h REVISIONS-STRUCTURAL/COLUMN/CONCRETE
"Maw, of '4;' Y99 S L LINTEL FOR EXTERIOR DOOR
H �SDE�mCLA ATP16 NO NEW PERMIT-ORIG 05090214
1 une,creand my play x,Mall be usW as public micro--
>yU
Liccmcd Pmfcaioul '
OWNER BURDER m ft CoAT10N \
C n O 1 hereby.(Sc that I i. exempt from ttr C.tis Co Incense law forthe
y
p O fol Imine m xan. permit t ]fn I.S,B�alnus a�Profetaiom Code:Any cM a minty V
$ which im mato•e.alm recorsvrtsct.slnr,mfor auaopmM deermitt flea repair NYsumcmm .
peri-nosh, dP almm9.theear thcapaces a for mobpermitn ilk a Law(Chapter
that fi.mm�cin, ithSecwntnncpmvis orr3 hthcRuinezx fiarucloiv(Chaper9 Sq. FL Floor Area Valuation
5E (,a,Ma$inewithS-tiona Me
f3Mthe BuxI ex.Ntl Rofcaoionx Anyvilaade)of
S 3$ Nal be b eanopt Ihcre(rm W Ne buss far the a1keW eaNipuon Any MNUIan of
Section'/N 13 by agaFPlkam for a pem,It sobjena ibe appliom n I evil penalty of APNNumber Occupancy Type
eat m-e Nan five bombed Mbar(5500).
I,u orbta of tk properly,m mY unpbym vhb wgn u theh mle.mpmW.,
will Ao the wort am thcswaurt u n-tsmt-onreseE(-sale(sat.7011,Busveu
w Ihofexam s Code:The c.mcnr,Lia,.,e Law dna am appy In N owaes Of Required Inspections
property rho builds or lmpmv dr+rnn.and wbo docs audt work hivue lr-through thio
own empbyw.providN that such impmc eror ,r are,not Inrxdrd-offered for ale If.
hawser.the bolting-impmsenwu a sold within arc year of compkdwi.the owner. .
buitm wi0 hese the burtlm of purine that he did mu alt-impose fee pocrnae of
vk.).
❑1.as Pw.r ar the propsty..m euiui tey ranhactnp with licxmed comrcnbs le
consumer Ne project(sec.7010,B.I.and Proftesionat Code:)The Camncnr'.U.
cede far don nm appy n xeowmn of properly who b,dta co no m nem. Me
who ece,acs fm abed p,*m wih a conuactar(s)liceaed por.n&fmuaetae.
Lice.taw.
❑Ion eaemp orotic Sce .BdPCf-Nl.rtuon
m Due
WORKERS COMPENSATION DECLARATION
I be,eby aRhm uneer pemlt,of Xdory once of the following deximarionc
❑1 Noe and will mubtuie•CeNf^b•of CamNt n alf-imurt f-WartdsC-npa-
sabn, r which thpmvidt is
aso issu3700 of the lab-Code,fm Ne peRobmav¢N dse
vale fm ea pmnit u ed.
1 hale at will mannan Wortcrs Co npebuWon Inwnna.u required by Seel.
YM of the lab-Cade,fm Ibe pe f-man¢or the wont r-which Nis pnmLL B bot
My Workee'.Compemubo lnsurvt¢arriv aod Policy nmnbcr are
C.rk,.Af�i. .ralirY.J PLA Policy No.:16y(i 1-1-1
Pl OFE EMMON MOM WOR%FRS
COMPENSATION INSURANCE
mth;sentne bet not b,compkrd lithe permit 1y f-orc bvndrt claim.($109) .
rola )
I certify that In the p-f-mance of 0c w fur whkh Nls pennon u isaN.I.NII not
employ any pcnm in my mN.r to u to dxame sebjen to 0e Workers'OcMpemaion
laws of CalJamia Dare
Applkaa
NOTICE TO APPLICANT:If.after,mal this Ccnifatc of Exmnpti.,yeti a,oubl
became subjw to th Wortc'.Cumpematti pmvisiom of tic Lada Codt%you mut
.JO forthwith comply with such proisiom-this pmmh"I Inc htmW mated
zLEN
h .CONSIRUCIION DING AGENCY
lknory-intro that there I..cmaa-ti.kndine.emry lcr Jrperform.of
a> dte wort fm which this mnit u'«.,.n(sec ion.CN,C) .
QCarmel,Nurse
_U z Lamers AdMs,
U O 1 certify thea I hale new too appkuion am,sr thea the i bosc information is
[I.f-' cmrcck I cern ot cmroply with all city and county oncl ..».am swc law retain,to ,
�U buitinYcowructimn.Nd hembY authorirz mPm,enstirrs of Wacity nentuupbm the
W .love-mentiant property for inspection p-lessee
(We)agme In on,indemnify and keep h.rmleas the City of Cupertino againn
N li.bilitks.judemcnmcous aod expense wbkb may in my way..,loot said Cry
U Incutwa)tier,ceafchat pantingmfthisporob- Jr-pG
^ APPLICANT UNDERSTANDS AND W L COMPLY WITH ALL NON-POINT Issued by: Date v
SOURCE LATIONS.
'ate - Re-roofs
enaum �IbHAZAARDO S ATERIAIS DISCLOSURE J Type of Roof
Will the appncavt-Tut 'Iding o¢upant aortahamkhauNom makrW
as tlefircd by the,CuWU.Mu pat ode.Chaper 9.11 am the Haldt am Safety
.snti.05532W7 All roofs shall be inspected prior to any roofing material being installed.
❑Yn
Will neapplicant or mt„m bwlam,aavpam mceympmNt-clavian wnbn If a roof is installed without first obtaining an inspection,I agree to remove
emit haaudou err mnUmimna u deMcd by the Bay Area Air Quality Mwpemeut all new materials for inspection.
DWx't'! �// .
❑Yrs �ry /
I base read the haadosmuer tfi,regoiremens.derChpW&95aft Califm.
n Hk &any Cade.Swfv 50.5.25533ara125531.1ubdcmardthatifclic buiktic,
dam roe<nrc Y wK a bn,Nc thm It y reapomlbilLLy notify de ae.ant N dr
reyu' ieh roma lx met prior M a CmUfose of
Signature of Applicant Date
wnmrvm. lit _ urn - All roof coverings to be Class"B"or better