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02060132CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEKNNO 0 6(/, c�13Z APN # Date: Building Address: �-� mo D -LN 4Sq�7a��a-S�nn Owner's Name: Phone #: 3-0 ( si cl NOS) Contractor: 3-v— I_-zAK-t YZ�lr.�io� License #: ( 13) Contact: �Aj;%*c 3,AK-r. Phone #: (Z10,9 &79 - 35i Applicant/Contractor: Fax #: BUILDING Cts) B . ding Permit Info: ldg Elect Plumb Mech Jo ription: � " Residential: d /A Commercial:'jZ Pq i Q_ PSTj o& V2FsetiA Sq. Ft. Floor Area: �BP- $/Sq.Ft.: Architect/Engineer: Valuation: Cx?p. ELECTRICAL BELEC1001 Type of Construction: Occupancy Group: RE ®i (Lxi - , �o Elec Svcs 600V <= 200A �aaanti Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Conu /Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax — Resi/Mobile BUILDING BELEC1000 Elec 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi -Family Res MECHANICAL BNEWMULTI New Multi -family Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING 1 of 3 oop) CITE OF CUPERTINO; CONTRACTOR INFO 'ON: BUILDING DIVISION PEOT BUILDING ADDRESS: PERMIT' NO. 20620 HOMESTEAD RD JK BAKER CONSTRUCTION 02060132 OWNER'S NAME: APPLICATION SUB DATE JOY BELLI (PW MARKET) 2175 STONE AVE. #11 06/20/2002 PHONE: SANITARY NO. CONTROL NO. .(408)882-0199 ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH lu r 1� L=_j LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby affirm that 1 am licensed under visions of Chapter 9 (commencing with Section 7 ) of Division 3 of the Busine p` d Professions Code, and my license is in full fo d !„ �1/ REPAIR EXISTING CANOPY i e effect. ✓ �, r Lice u CI Lic. # �•d' .Fo 1 lJ i a Contractor i ARCHiTECf'S DEC ON i 1 understand my plans shall be used as pub c records i Licensed Professional t OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the ' following reason. (Section 7031.5, Business and Professions Code: Any city mr county $7000 i which requires a permit to construct• alter, improve, demolish, or repair any structure - - -- - •- ---•-- -- -- i Prior taimissuance, also requites the applicant forsuch pemnitm filea signed statement that hi:'Is licensed pursuant tq.the prgvisions of the Conrracmrs License Law (Chapter 9Valuation (commCricing with Secoon.7000) of Division 3 of the Business Professions Code) and or thai he Is exempi tfnemFmm aid the basis for the alleged t}c6mptioa. Any violation - of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not mom than five hundred dollars ($500). 101 APN Pb AT I ON Occupancy Type ❑ 1, as owner of the property, or my employees with wages as their sole compensation,PT will- do the work. 'andVte structure is not Intended or offered for sale (Sec: 7044,--- ' Bbdiness and Professions Code: The Contractor's License Law does not apply to an 103 - UFER Required Inspections � �- owner of property Who builds or improves thereon, and who does such work himself or through his own employees. provided that such improvemenrs are not intended or 10.4 - REBAR c erele for sale: wrier build the building or unproof proving n that he did one year of completion, the owner -builder will have the burden of proving that he did not build or 10 5 — ANCHOR BOLTS ' •' improve for purpose of sale'). 106 - SEWER & WATER - 1. , as m6ner of the prog;i y, a n exclusively contracting with licensed contractors to --" .._ -•---'2 O 2 - UNDERFLOOR PLUMB ING --- -- r •.' � ` - --� ''"."`'' � - - --- - construct the project (Sec. 7044, Business and Professions Code:) The Contractor's License Law does not apply to an owner of property who builds or improves thereon, 203 — UNDERFLOOR MECHANICAL _acrd who cpntracts.for such projects wim.a..coatractor(s) licensed pursuant to ttte. Contractoes License law. , -204 — -UNDERFLOOR '-FRAME._. .._...----_.__.. _-. _ _ _.-. -- . ---- ❑ I anti exempt under$ec: , B & P C for this reason 205 — UNDERFLOOR' 'f PNSUIIAT ION Owner Date 301 — ROUGH PLUMBING ' . WORKER'S COMPENSATION DECLARATION 302 — TUB & OR SHOWER I hereby affirm under penalty of perjury one.of the following declarations: 303 — ROUGH MECHANICAL ❑ 1 have and will maintain a Certificate of Consent to self -insure for Workers 304 — ROUGH ELECTRICAL Compensation, as provided for by Section 3700 of the Labor Code, for the berformance of the work, for which this permit is issued. 305 - FRAME ❑ 1 have and will 6Wntain.W.orker's Compensation Ins6mrce,'as required by Section 306 — HOLDOWNS 3700 of the labor Code, for the performance of the work for which this permit is Mi issued. M' Worker's Com nation Insurance tamer and Policynumber are: 307 — INSULATION CERTIFIC t�ENSATONQd'URA °�` s h tt3af %(....'308 `=tic SI�EETROCI , `_._ ;1,_. , ..` 'EXTERIOR 309 '— LATH ... ... ... .. .. ` .... 10 ;-',-INTERfiOR —LATH- •-- ------------ -. Mid section need not be'compieted if the permit is for one hundred dollars (s100)or leas.) ., •, ' -' ` 311 - SCRATCH COAT I certify' mitt in the perfontiance of me work for which this pemrtit is issued, l _ 313 ROOF NAIL `` shall -not employ any person in any mariner so as to Secome subject to me Workers' 501 — F I NAL ELEC'TRT CAZ ENERGY ComiCgnL con Laws of califmmia. Date Applicant � ' � - 5 0 2 — FINAL NAL -PLUMBING ENERGY-. NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers Compensation provisions of me labor Code, you must 5 0 3 — FINAL MECHANICAL ENERGY forthwith comply win such provisions or this permit shall be deemed revoked. .504 - _ F I NAL _ BUILDING_ -ENERGY. i CONSTRUCFIONLENDINGAGENCY r Thereby affirm that mere is a constructioti lending agency for me performance 505 - FINAL ELECTRICAL a of the work for which mis'permit is issued (Sec. 3097, Civ. C.) 506 - GAS TEST Lenders "ane '- Lender's Address 507 — F I NAL PLUMB,Ii. NG...... I certify that 1 have read this application and state that the above information is 'correct, 508 — FINAL MECHANICAL I 1 agree to comply with all city and county ordinances and state laws relating 509 - FINAL GRADE ? to building construction, and hereby authorize representatives of this city to enter upon ( the above-mentioned propM for inspection purposes. 510 — FINAL PLANNING r (We) agree to save, indemnify and keep harmless the City of Cupertino against 1 liabilities, judgments, costs and expenses which may in any way accrue against said 514 — FINAL UB C WORKS City in consequence of me granting of this permit. SAPPLICANT OURCE RE UNDERSTANDS AND WILL COMPLY WITH ALL NON. INT Issued by: D e (/ L - natureol'Applicant/Contractor Date Re -roofs ' HAZARDOUS MA LS DISCLO ' ' Will die,applicant or future buil - cupant st r handle hazardous material Type of Roof .. ... _. ...._ . .. .. - . , .- ,.. _ ... _ .. _ .... • - - as defined py the Cupertino Munici , Ch 9.12• and the Health and Safety Code, Section 25532(a)° °Yes'' All roofs shall be inspected -prior to any roofing material being installed. ,will me applicant o e b ing occupant use equipment or devices which hazardous If a roof is installed without first obtaining an inspection,' I -agree to Iemove emit air con s cfined by the Bay Area Air Quality Management District? all. new materials for inspection.. Applicant understands and will comply with °"� ° No all non -point source regulations. I have read a azardous materials requirements under Chapter 6.95 of the California Health Eery Code; Sections 25505, 25533 and 25534. 1 understand that ' if the building does not currently have a tenant• that it is my responsibility to notify the - - - - - -- occupant of me requirements which must be met prioi to isluance' a Cemifncate of Occupancy. Signature of Applicant Date ?8 0� All roof coverings to be Class "B" or better' nerorauthorized agint a OFFICE - Plan Check Division p 10300 Toife Avenue ago Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 CE JUL 112002 i an Department S 'Ec�]I�IL INS ANY TESTING AGREEMENT Project Name: '� �� - Date: Project Address; -or � ZQ hL"C5,T Bldg. Permit No: To permit applicants of projects requiring Special Inspection and /or Testing per UBC Section 1701. BEFORE A PERMIT CAN BE ISSUED: The Owner, General Contractor, Project Architect/ Engineer and Special Inspector shall acknowledge the required special inspections, testing and conditions. When determined by the Building Inspection Division, a pre -construction conference with the parties involved will be held to review the special inspection requirements and procedures. Special inspection and testing shall meet the minimum requirements of UBC 1701. The following conditions are also applicable: 1. Contractor is responsible for notification to the Special Inspector or Agency regarding aJ pections for times listed on the attached Schedule and noted on the City dequate notice shall be provided so the Special Inspector has time to th the project and do a thorough job for all inspections. �� P J g J P s�9 or shall submit his qualifications to the City and is subject to a personal 3rL erv' w for pre -qualification. Special Inspectors shall display an approved identification r - - = e the function of a special inspector or upon request, and must have a } his y0` o pl ns jam` g P P P q Ve !;s!,t nn tit �xOfigation for the type of work being inspected. Ialrfa! 'to make any chanjos or otDPt 4ons UP S?rne31Y00ut@sMid' 9@sp iodhties of the Special Inspector are: Ilrr ilmldini , Dept., City of CUpoitho, '(iir ';'ilmrnlf1p nt th' plan ap ��, �,>�.��9,�r' e 6Vq"6v �"e work for conformance with the= APPROVED riP,l r IUfll ho hcNo Dor It Or "15 11, �rnvr,l of Pho violation of sign drawings and specifications and applicable O,or rpoAaanship Provisions of the UBC. NOTE: Shop drawings may be used o_ my as an aid to inspection. B. Bring non -conforming stems to the immediate attention of the contractor and note in daily report (Ref. item 4). If any such item is not resolve in a timely manner or is about to be incorporated in the work, notify the Building Inspection Division immediately by telephone (408-777-3228) or in person, and the Project Engineer or Architect. 1/3 Revised 6/13/00 i D D Plan Check Division 103.00. Torre Avenue = Cupertino CA 95414 ` Telephone (408) 777-3228 TO Fax (408) 777-3333 C. Furnish reports of tests an inspections directly to the Building Inspection Division„ Engineer and Architect of record and others as designated. These reports are to include the following. • Describe inspections and test made with applicable locations • List all non -conforming items • Indicate how non -conforming items were resolved or indicate unresolved items as applicable . r n on changes authorized b Architect, Engineer, and Building Ins ecti Division of not included in non-conformance rmance items D. Insure that an adequate number of pre -qualified special inspection personnel are on the job based on the intensity of activities, quality of work being performed and the various operations occurring. E. Submit a FINAL LETTER OF COMPLETION to the Building Inspection Division stating that all items requiring special inspection and testing were accomplished, approved and reported and, to the best of his knowledge, in conformance with the approved design drawings, specifications, approved change order and the applicable workmanship provisions of the UBC. Item not in conformance, unresolved items or any discrepancies in inspection coverage (i.e. missed inspections, periodic inspections when continuous was required, etc.) shall be specially itemized in this report. F. FINAL LETTER OF COMPLETION shall be signed by the Licensed Registered Engineer of the Special Inspection Agency of record. 4. Each Special Inspector shall complete and sign the Special Inspection Record at the job site or each day's inspection and provide a daily handwritten report in a format acceptable to the Building Inspection Division to remain at the job site with the contractor for review by the Building Department's Inspector. Content of the daily reports shall be per Item 3C above. 5. Work requiring special inspection and the performance of special inspection shall be monitored by the City's building inspector. City approval is required prior to placement of concrete. General Contractor shall notify (408-777-3228), 24 -hours in advance for each day special inspection will be conducted. 6. Special inspections are to be performed on a CONTINUOUS BASIS, meaning that the SPECIAL INSPECTOR IS ON SITE IN THE GENERAL AREA AT ALL TMES OBSERVING THE WORK REQUIRING SPECIAL INSPECTION. Periodic inspections may be approved by the Building Inspection Division and, if approved, shall be noted on the SPECIAL INSPECTION AND TESTING SCHEDULE. 7. Only the City approve Testing Agency of record shall sample, transport and test materials. 2,3 p w; r•�,Y� Revised 6/13/00 +0 l br-Je . Rry �� ..�r✓Go,nt,y)� r �! ,a CUPEkTINI • JUL 112002 c, D P Plan Check Divisit n J 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax(408)777-3333 Building lie gart�,i"[ Project Address Project Title SPECIAL INSPECTION AND TESTING To owner of projects requiring Special Inspection or Testing per Chapter 17 of the 1998 California Building Code, please acknowledge and return to the City. BEFORE A PERMIT CAN BE ISSUED: The Owner or his representative, on the advice of the responsible Project Engineer or Architect, shall complete, sign and submit the attached form "Structural Tests and Inspection Schedule" to this Department for review and approval. The owner and his general contractor, where applicable, shall also acknowledge the following conditions applicable to Special Inspection and/or testing. 1. Contractor is responsible for proper notification to the Inspecting or Testing agency for items listed. 2. Testing laboratory only should take samples and transport them to their laboratory. 3. Copies of all laboratory reports and inspections are to be sent directly to the City by the Testing agency. 4. Inspection agency to submit names and qualifications of on-site special inspectors to the Building Department for approval 5. The Special Inspector is under the authority and is responsible to the Building Official. All inspection concerns and/or problems encountered are to be brought to his attention immediately. 6. Special inspectors may be required, as a minimum, to provide weekly reports to this department of all inspection activity. 7. It is the responsibility of the contractor to review City approved plans for additional inspection or testing requirements that may be noted. 8. BEFORE AN OCCUPANCY PERMIT CAN BE ISSUED: The inspection agency shall submit a statement that all items requiring testing and inspection were fulfilled and reported. Those items not tested and/or inspected shall be note in this statement Copy of statement to be maintained at the job site for City's Building Inspector's review prior to final inspections. ACKNOWLEDGMENT BY ALL PARTIES CONCERNED s Signature 1/3 Revised 12/17/01 City Plan Check Engineer Signature r. Plan Check Division 10300 Torre Avmue • ih s , 6 7,e D Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 8. Only the City approved Special Inspection Agency of record shall provide special inspectors. Independent inspectors may be pre -approved by the Building Inspection Division per Item 2 above. 9. BEFORE AN OCCUPANCY PERMIT CAN BE ISSUED: The Special Inspector or Agency shall submit a FINAL LETTER OF COMPLETION per item 3E above directly to the Building Inspection Division. 10. Copy of SPECIAL INSPECTION AND TESTING SCHEDULE, SPECIAL INSPECTION AND TESTING AGREEMENT, SPECIAL INSPECTION RECORD, and SPECIAL .•INSPECTION DAILY REPORT, SHALL BE AT THE TOB SITE. ACKNOWLEDGMENTS Signature Owner: ' General Contractor: Special Inspector or Agency: Project Engineer/Architect Building Inspection division: CompanX West Valley Shopping Center,Inc. -JK Baker Construction W14sting Engineers, Inc. MSI Consulting Engineers, Inc. JUL 11 2002 3/3 Revised 6/13/00 o" Plan Check Division Vr_ 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 STRUCTURAL TESTS AND INSPECTIONS SCHEDULE Prior to issuance of a building permit, the Owner, on the advice of the Architect or Engineer, shall complete, sign and submit this form to the Building OfficiaL Project Name V Date e, c-77 o ' Project Address Testing/Inspection Agency Owner's Nam Signature & Title hereby certifies that the Testing/Inspection Agency named above has been engaged to perform structural tests and inspection during construction, as checked below, to satisfy all applicable portions of the Building Code. Prior to issuance of an occupancy permit, the Inspection Agency shall submit a statement that an items of designated work performed were reported. Any items checked but not tested or inspected will be noted and explained. Whenever any designated items on this list are ready for sampling, testing, or inspection, it shall be the responsibility of the Contractor to give timely notice to the Inspection Agency so that the required services may be performed. REINFORCING STEEL: _ Tensile & Bond, one set per heat per ._tons _ Inspection of Placement _ Inspection ofWelding JUL 112002 MASONRY: _ Preliminary Acceptance Tests(Masonry Units, Wall Prisms) _ Subsequent Tests(Mortar, Grout, Field Wall Prisms) _ Inspection of Grouting _ Inspection of Placement & Grouting CONCRETE, SHOTCRETE GROUT & MORTAR: Conc. Shot Grout Mortar Aggregate Tests for Resigns Suitability of Aggregates Mix Designs Test Panel Batch Plant Inspection Cement Grab Sample Inspect Placing Compression Tests Cast Specimens Pickup Samples Shrinkage Bars Yield Check Air Check Dry Unit Weight 2/3 Revised 12/17/01 STRUCTURAL STEEL: Sample & Test (list specific members below) ,—Shop Identification & Welding Inspection —Shop Ultrasonic Inspection Shop Radiography _ ,Field Welding Inspection _ Field Bolting Inspection _ Field Ultrasonic Inspection Field Radiography _ Metal Deck Welding Inspection ASPHALTIC CONCRETE: _ Mix Designs _ Inspection of Batch Plant Core/Test _ Field Inspection Suitability Tests —Specific Gravity Asphalt Content Sieve Analysis K Factors Stabilometer Value _ Swell INSULATING CONCRETE: Sample & Test — Unit Weights 4 p Plan Chec1: iivision 10300 Torre Avenue Cupertino CA 95,014 Telephone (408) 777-3228 y�Jl 11 2442 �'�� Fax (408) 777-3333 PRECAST/POST-TENSIONED CONCRETE: FIREPROOFING: Reinforcing Tests _ Inspection of Placement — Inspection of Reinforcing Placement ^ Density Tests ' Tendon Tests _ Thickness Tests — Inspection of Tendon Placement Inspect Batching _ Inspection of Concrete Placement Inspection of Concrete Batching FILL MATERIAL: Inspection of Panel Attachments & Inserts _ Acceptance Tests Inspection of Panel Installation _ Moisture-Density Determination _ Compression Tests _ Field Density Inspection of Stressing/Transfer PILING, CAISSONS, CAPS, TIES: ROOFING: _ Inspection of Reinforcing Placement _ Inspection of Placement _ Inspection of Concrete Placement — Sample & Test Inspection of Concrete Batching UNDERPINNING: STRUCTURAL WOOD: Inspection of Steel Fabrication _ Inspection of Fabrication ^_ Inspection of Reinforcing & Forms — Inspection of Truss Joist Fabrication Inspection of Concrete Placement ^ Sample & Test Components Inspection of Tiebacks _ Inspection of Glu Lam Fabrication Shear Diaphragms ADDITIONAL INSTRUCTIONS OR OTHER TESTS & INSPECTIONS: Go CR,16c/ 1h--/o,1jt, a Go�c rzLj6 �� ► �c.� i•✓f �,,rU�tt� R� �i,SJ 6-1/0Gcf-ty, 3/3 Revised 12/17/01 OF NO CITYILD � CONTRACTOR INFORMATION: NG DIVISION PERMIT BUILDING ADDRESS: PERMIT NO, 20620 HOMESTEAD RD JK BAKER CONSTRUCTION 02060132 OWNER'S NAME: APPLICATION SUB DATE JOY BELLI (PW MARKET) 2175 STONE AVE. #11 06/20/2002 HONE: SANITARY NO. CONTROL NO. (408)882-0199 ZO ARCHITECTMNGINEER: 0 BUILDING PERMIT INFO BLDG ELECT' PLUMB MECH I "I CI Gl CJ i LICENSED CONTRACTOR'S DECLARATION 1 hereby affirm that 1 am licensed under pry�isions of Chapmr 9 (commencing with Section] ) of Division J of Ne Bain v1=11,0unsaKe.aadmyheeme Job Description �� REPAIR EXISTING CANOPY ��E® in roan foe nd e(rttt. ✓f� (p 3(044(0 Lice GI Convenor APR 1 0 2003 S DEC ION '79 ARCHall ba i 1 understand my plans shall be use] ea pun c records BUILDING Licensed professional RATION lea Oat I am eUILDE from the License Lew for Ne ro 1 hereby .(firm that 1 am exempt from the Cessions meson. reaction ]oJ LS, Business and Professions Code: Any city or county Ca D $7000 which re which requires a permit ac construct, aper, improve, demolish, or repair any stmcwrt Is requites be applicant farthe $,p resitsissuance,censedpursuant 1 3lQvt, 6�&1pOrrQ{'(:as h. 'f-j\r�i'. �',� ,,T.. b�.LO o0 Valuation License La (Chatent tha- Frshe)licensed parse O9the pm D,vi,iof the the Btor,,Lccnu law (Chapter Contractors ( mrnepc ngwthS a ](k90y of Dlvsnn 3 o the Busmcsa and Profess ons Code) or that he 14 the hos s far the alleged Any violet on tany i applicand -of Saliba a than by any applicant fora permit mbjttu the appliam to o civil penalty 31.5 byapplicantt !of hat more thin Eve hundred tlogars ($500). APN 101 1�ATION ' ,`rr �'P Occupancy Type ❑ I, as owner of the propeny.0 my employees with wag"" their sole compensation, erad or sanc -wilt c e wark."and Ne ode: The is not intendContractor', Law doe sole (Secyload,- (Business Lima. License law Joss not apply m an Case: The Cves - - --- Required Inspections • 103 - UFER '' • o property Who b ids orimpra s N and wh d s ch n lf theme Uro 10 4 REBAR a gh his own employees, int ed at fo s wf.oweprovided that h p i s t e intended r building Improvement e's6ldtha within one year of "'completio owns alder will have the huNenafpmving that he did not build or improve _ 105 - ANCHOR BOLTS t•' " bi tapmn.1acherwll impro"`r°rp°'p""°r'°I°')' 106 - SEWER & WATER I -- -- ----- ---- -g with lien. -----'-- dLasowner -- --- 202' -"UNDERFLOOR --PLUMB ING—'—�•'i: �.::G;;:;�%-n h-�--" rojettpropenyamBusinessandmrazungwitCWc:)sTheConctonm - License the mat (Sm. appl ]Doan Business pro Professions Code:) The vermcwrs low does not apply w an owner of property who builds improves Nw 203 - UNDERFLOOR MECHAN'I'CAL' d-wh and : ...andwctin'scontract.ense Lsuch.projects.with.a.commctorfs).licenue.pursuant-m.Ne. se the 'r. Conva<tor s License La _.___..__..2.0.4-'-'-"UNDER'FLOOR--FRAME.-.._.________.__.._.__...._..-...-._-.___-.. .. z ❑ l am exempi°ndeIr Sec ''1, li '=' Br&'PCforthi reason . —r--.----' . '' 205 - UNDERFLOOR`'"TNSUZ'ZATION owh2,"" ^ •h'r'^.',: Date'. 301 - ROUGH PLUMBING •'"WORKER'S COMPENSATION DECLARATION _ �I 302 - TUB & OR SHOWER hereby aRratunde.p<�,ItyafanjJry,bp�.grineranowingattleratian.:- 303 - ROUGH MECHANICAL 0 1 neve and wdPinadm iae'Cendiic6ia of Consent to self insure for workers 3 04 - ROUGH ELECTRICAL 1. Compensation: as, provided for by Section 37W of the Labor Code: for the 'perfartnhace of work for which tins pcimd is issand. 305 - FRAME 01 hinm and ill m nm,n Wok 's C pc t Insurance, required by S ctioa 306 - HOLDOWNS 37M f the Labor Cod for the performance of thin work f which his rout Ij i M My Wo k es C in ensouon Inx c en'd Pal ry & er<y 307 - INSULATION °Po cyN ay 2 LN-rOol 76(• 308; =1 SHEETROCK luatL , �_ _ _... '�ftCER11FlCAT10N.OF,E%EM I OM WORKERS -41 ":- 'u =-% i3i09 '-'/EXTERIORI ILATHf' ;- COMPENSATION 1 URANCE _ .,3.0 Issl 1Th2s cllan ed rid he k,mplemaf the Permit is hundred . '� \ I•- s' .t'.i 1 1 - SCRATCH COAT (aldol ries) i y caro thea In th rfosmnn.. ohne wo k r, .. -- - h,, pc when thl is nsued'1 --i-3 13: _-•--ROOF-= NAI L-."•°: - - .._...... __ .- `, r ,permit shall not empl y any peno n any manner, so as to subject to the W hart' �,. ..•.-,t v 5 01 - FINAL ELECTRI CAI; -ENERGY _become compcnso0oa lawsarCalif. mia Dnte - .. _ ..502. -.lien -FINAL --PLUMB ING_ENERGY__..._.. __. illi.. -. ... - • NOTICE TO APPLICANT. IL eller make glhis Ccnifica�e of Exemption, you' should become -smns 503 - FINAL MECHANICAL `ENERrGY subject to the Workers Compensation prov of the Labor Code, you must fnh'Ith 'ply'uhsuehp th pe" mit shallbedeemJrc ked y... n _,•.. illien.. _. ....._... .. .... ............ ,_.5.0.4;-.-_.F.INAL_..BUILDING__ENERGY---..._._ ,T• CONSIBI Ti'ONLENDING nGENCY thereby ufErm that there t . contraction led g ag ncY f th perform ce 505 - FINAL ELECTRICAL'..l- i! t -- ' : ,.' ... l . . ofth weak far hichm peimitisissuW(Sec'l QvC) s; a� - -(s de sham - Lender Address; 506 _- GAS TEST - -, __ - --- 507 - FINAL PLUMBING..,..--'----- -- ----- term fy incl l have rted this Gepp canon and sate Nanhc above infoemet ons I 508 - FINAL ME CHANI CALL 1 eorlen. 1 "ana complywith all city end county, ordinances and state laws relating w building cansvoctionf and hereby authmi'm, representatives MNis city to enter upon 509 - FINAL GRADE a the above one miaunitpmplertyfar inspcctionpurposes.� ., 510 - FINAL PLANNING _ (Wej agree to save,.indemmfy and keep hatmleis Ihre Ciiy of Cupenino•'agaim, I liabilities, juagmcros, costs and expenses which :may .inanyway,acemeagaim,said 514 - FINAL UB C WORKS City mwequrnce of the joining of this' perms ' " " ' i APPLICANTUNDER$r\NDSAND WILL COMPLY\\'1TH ALL\ON-1 )IVTt' ' 40URCCREC V lJ Issued by: D e \rr , 1 �'/.�_/' nature l'ApplicartComtano -rt •1 f• .Dies MAT ` -, - l� Re -roofs I.xCaderSeaHAZARDQUS L5 DISCLO RE ill the ppliant fuw a MITI puns i - r handle hazard mmenal .l Len Type Of. Roof.... - Y pan n Man i e Cha 9 I3 d the Health and Sar ty ia) L IVY is - ❑Yew f,i' in. _.L ,t ynyltr _:\ -k All roofs,stiall he, inspected riot to -any roofing. material being installed Will the .,,coal I goccapantuse aqu pmem on favi nswhich- - If a roof is inst311ed without first obtamtlig an;inspectio`n Ilegree to remove ems barara air coram s at, ad by the h Bay' Air Quality Management D con all new materials for inspection Applicant understands and, will in y- with ❑Yes ❑N _ --,- - all hon -point source regulations u 1 have tmdous maanals rcgwremenia under chapter h 95 curb nd Net al that CehPomiaing fety Cade,are amsm,,a ' itti rand - if the building dins not it is in, y have a tenant; Nat it is my .Iponsibila to ratify the Y - y s'• , r, oecupanl of the rc'quircmcrs which mass be met priories issuance' ' a Cenincarn of erns Onvpnncy ' -' - Signature of Applicant Date All roof coverings to be Class B" or'better ice ra to sea g t , OFFICE....._....- .. illi._ .. _ illi _. .......... illi..