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02010110coat 5 0 0 yUU ZW tt-. _z 024E -a �Y� XrQj C6 t- U. 0 C 4 aao� I—za KFS m a3 - Oz z2 CITY OF CUPERTINO BUILDING DIVISION PERM, BUILDING ADDRESS: 10804 BROOKWELL DR MOCELIN CONSTRUCTION PERMIT NO. 02010110 1537 ORILLIA CT TT'tT9 WU2 PHONE: (408)732-6655 SANITARY NO. CONTROL NO, ARCKITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH FI (—I L 7 L=J LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing bb D p� ADDITION TO EX I JS�T I IG&nU�AGE with Section 7000) of Division 3 of the Business and Professions Code, and my license 3CW140Lic. -iCon J t "S RATWN P5�;� I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Section 7031.5, Business and Professions Code: Any city or county, $12000 which requires a permit to construct, alter, improve, demolish, or repair any structure prior to its issuance, also requires the applicant for such permit to file a signed statement _ "` 3 6 2 -0 �r;•A ,, Valuation that he is [icegsed puesuant to the proyision of the Contractor's License Law (Chapter 9 (comtr)encing, )vith,Section 7000 of Division 3 of the Business and Profgssions Cody 1 ;� '� ; or that he is exempt therefrom jnd the basis for the alleged exetnplibn. Any violation ' of Section 7031.5 by any applicant for a permit subjects the applicanrto a civil penalty of not more than five hundred dollars (%500). 10 1AP-N MINDAT I ON Occupancy Type 111, as owner of the property, or my employees with wages as their sole compensation, 102 - PIERS will do the work, and the structure is not intended -or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply roan 1 O3 - UFER Required Inspections owner of property Who builds or improves thereon, and who does such work himself 104 — REBAR or through his own employees. provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of _ _ -105-- — ANCHOR BOLTS completion, the owner -builder will have the burden of proving he did build improve for purpose of sale.). ng tnot or 106 — SEWER & WATER ❑ 1, as owner of the property, am exclusively contracting with licensed contractors to - 202 - - UNDERFLOOR PLUMBING construct the project (Sec. 7044, Business and Professions Code:) The Contractor's 203 — UNDERFLOOR MECHANICAL License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the 204 — UNDERFLOOR FRAME contractors ptunder Sec. : License ❑ I am exempt u ec, B &�P C for this reason 205 — UNDERFLOOR INSULATION 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 ME CHAN I CAL ❑ 1 have and will maintain a Certificate of Consent to self -inure for Workers 304 — ROUGH ELECTRICAL Compensation, as provided for by Section 3700 of the Labor Code, for the 305 FRAME performance of the work for which this permit is issued. - 111 have and will maintain Worker's Compensation Insurance, as required by Section 306 — HOLDOWNS , 3700 of the Labor Code, for the performance of the worst for which this permit is 307 — INSULATION issued. My Workers Compensation Insurance carrier and Policy number are: , 308- — SHEETROCK- ier: '• Policy No.: Cart'309 CERTIFICATION. OF EXEMPTION FROM WORKERS' n • ' ' 3 0 7 LATH. COMPENSATION INSURANCE -31G - . I'NTER'I-ORLATH '- - - - - - (This section need not be completed if the permit is for one hundred dollars 311 — SCRATCH COAT (S 100) or less.) 313 — ROOF NAIL I certif that in the performance of the work for which this permit is issued, 1 shall not empl any pens i an mdnner so ss ° b me sabeet rm [hew°rke�' 501 — FINAL ELECTRICAL ENERGY Compensa into a. v Z Applicant 502 — F I NAL PLUMBINGENERGY ENERGY NOTICE O PP A .. f, his Certificate of Exemption, you .should 's 503 — F I NAL ME CHAN I CAL ENERGY become subject to a Worke Compensation provisions of the Labor Code, you must forthwith comply withsuch pr°vision or [his permit shat be deemed revoked. 504 - F I NAL BUILDING ENERGY CONSTRUCTION LENDING AGENCY 505 - F I NAL ELECTRICAL I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ, C.) 506 — GAS TEST Lender's NaTAddress 507 — FINAL PLUMBING Lender's ss Addre _ f 508 — FINAL MECHANICAL I certify that I have read this application and state that the above information is collect. I agree to comply with all city and county ordinances and state laws relating 509 — F I NAL GRADE to building conswction, and hereby authorize representatives of this city to enter upon the above-mentioned property or inspection purposes. 510 — FINAL PLANNING (We) agree to save, in mnify and keep harniless the City of Cupertino against 'udgment 514 — FINAL PUB C WORKS liabi t co s expenses which may in any way accrue against said City n co quence f t ming of this perms[. at�� A US MATERIALS DISCLOSURE Will appli t or re building occupant store or handle hazardo s material Type of Roof as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)? ,. ° Yes ° No All roofs shall be inspected prior.to any roofing .material being installed. Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? all new materials for inspection. Applicant understands and will comply with Cl Yes Cl No all non -point source regulations. I have read the ha doss materials requirements under Chapter 6.95 of the forma Healrh & Safer ode, Sections 25505; 25533 and 25534. 1 understand that i th wilding d a tenant, that it is my responsibility to notify the cu nt the us[ be met prior to issuance of a erif[cate of d ane °p Signature of Applicant Date D� All roof coverings to be Class "B" or better ate OFFICE =:.. .. ................... 14,11F.mm;mvislov PERNUT �C Q NTRA CU")R GN 1z' ................ ....... HZIT C 2 rl I Cl I I ij f 2, CrIl 0 2 727MYV'A L .r CA D4 C$.? ..................... 11"Xi STING GT\ a,T ny IN5;,amw: AQp Dr.0.$s sw.n.s.. Ll f�-�A I ON RE PH ul n�CRUIJIE_ F-I MULIIAiNil GTY 11 itlF ll UFLNI IAL gil tl�lt NI'M I E,5 1 C!t I r R 0,%1, r-�PAQ: 'A ............ (dl mm Rmmp ....................... N"\F�,jmjN(:,or)o[ ......._,. .3... i a1 halial tj ....... f:A j 7......... L L 1��T 410,p tlj�Tl M�i �!S RQ! V Ch ..................... t)r 11 N ................ 11 !�NAN I vI �6,�mk�'o..Inv, .................. ................... ......... ....... ............ I Y1.1;01, glum. L. j3ujl;A),,NV,4 r] Ll,F.-T 1_11171S'4.Sl IKYATR P.T., F AJl Sll1.11 . L ............- PIJTIZICAI l?",ally w"j.j &T.,'I PT's PsMln, s d^ 7 'I I IIA10D 1U.)U AVN 4E 5HItARAOW rco;,4 ------- INKVtqON lsi;l.(J Al,I N.s PI I-I I oN I,,il wii:n cj Lhl i. IN, ............. ....... HAS .......... ........... ................ .................. ............. ....... ........... MXNNIN;', ('.As-,I". ........... ............. ...... .I t rAT 777 EN llav 1F4 q"iL.,fw vl�0!610­� .. ............. • PR�.1'\S!'] '11C fNSP, ............ ISI ...... A PATTENS ...... VA No OSHA APPROVED ACCESS 0 R00F.,03HALL BE.PROVIDE D FOR INSPECTION ?0 d U L L a=>OVJ Z)0 C' dtG : TO ZO-9I -400 CITY;OF CUPERTINO BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: BUILDING ADDRESS: PERMIT NO. 10804 BROOKWELL DR MOCELIN CONSTRUCTIONss�� 02010110 1537 ORILLIA CT A�t1G� o$"692 PHONE: (408) 732-6655 SANITARY NO. CONTROL NO. acelic ARCHITECT/ENGINEER: BUILDING PERMIT INTO _ E t 6 BLDG ELECT PLUMB MECH y<y Ul O LJ LU] Z S N i LICENSED CONTRACTOR'S DECLARATION ybb DDez Rt�tt Da-o Ihereby affirm that l am licensed under provisions of Chapter 9(commeneing ADDITION TO EXI�STIN�nU��AGE pv,fjw with Senion]000)of Division3 of,he Buzincsx and Professions Cade.end my lianu s x E is in full foreya d eRec.. < Li=enuCia.S 3�lKG Lic. e•.6 V IC Lic.'#a��tyylIrr a a� ITECT'S DECyARAr — r � p i3 y 1 undemand my plans shall be used as public records -- - - 1�_- !p O���( w n p O Licensed Professional !/(' c x-(< OWNER-BUILDER DEIN- r'_, . w-w Ih by firm N,1 a p,from M- L eL�' I 2za following . l5em 703158 mesaandfie n O y`�=,ty�',, lar .. •1gd/^ r r $12000 zFs-oo which req ss n perm„,a co s, , alter,tmprose,de hs ran , i 3 pnorm¢issuance,aim q ,h 'pphcm,fur such, I, fleas gn ,. _ lF3 •.+- "a _-.- NI' .W pun am, ,M1 prq ions of Ne Conava. L canoe Ln (= mni<c g HSi,uU 7000 of Division 3 of Ne Basmps and ;•=;� 3 �C 9S$a a Valuation Pro'. la,onr a ;�1..i )b .'+: or that h n mPt therefrom and the bass for the allege. s tart e violation ° ° affection 70315 by tiny aspirin,for a permit subjects,he applicant m a civil penalty N of not man, an five Initiated doll am(ss0m. l 01APN 18'p�gpAT I ON Occupancy Type Dl as owner Ofthep perry y employees with wages as their sole compensation, 102 - PIERS_ aPq e -will do the work and'he t , m's no,intended.1 offered for sale'tsec-70x1; 103- - UFER 'Bae nets and Profess Cod Th Contractors License Law does not apply m an Required Inspections' owner of pmpeny Who builds or improves thereon,and who docs such work himself 104 - REBAR Onhrough his own employee..°....tied that such Improvements are not intended.. t OCToffered farsale-IL ImUevei,the buildingor im - -_.... _..__... -.. _. ____,_-l-., _ mproofsawngthahedidno<ywror TO5 ANCHOR--BOLTS-- T 1 ��'2002 completion.N a bn'm will have burse ary vngm,n as nmbuuaar 106 - SEWER & WATER imp f p ryo L I I • of u e rim praDeny cwt ly dm_ t Bw,EI dacdc 'iae,drsm ... _.202-------UNDERFLOOR--PL-UMBI NG �I�,( a i ttheD 1 ,(sc.Yaw business andProfessionscoda)T ve,thems 203 - UNDERFLOOR MECHANICAL:.': and wh Luo does nut apply man owner Of property who)lids seimproves Hereon, ,- " and who eomrvcous foasuch projects with.a comrac,.r(s).Bcensed pursuant m.Ne. Can,mctnrs uceme Law. -- _ _.204 ---UNDERFLOOR--FRAME- -_ ._....----.. ---........... .. ....____ . il ❑I am,esemp,Under,Soc '','B&P C for this reason 205 - UNDERFLOOR. INSULATION Gone,., ..Dom 301 - ROUGH PLUMBING WORKER'S COMPENSATION DECLARATION 302 - TUB & OR SHOWER Inereby affirm.neer P<naltyor perjury One af,,he following declarations: 303 - ROUGH MECHANICAL -, 0 1 have and wilPinninmia n Ced;ficate of Carlo., to,elf-insum for Workers 3 04 - ROUGH ELECTRICAL Compensation, as provided for by Section 37M of the kabor-Code. for ,he performanceaftheworkforwhicnNisp<,mi,i.is..�m: . 305 - FRAME ❑I have sad will'moiniain Worker's C.mpenem;On'Insumnce,.9 r<quirca by Section 3 06 - HOLDOWNS 37M of He labor Code,for He perfnrmance of He'work for which this am,it is 307 - INSULATION issued.MyW k s Co pc sato Inmm nJ Pol y h Cat - J:t.. 11.1 "t PolcyN 308 .. „SHEETROCK-,-.. t,CERTIFICATION OF EXEMPTION FROM WORKBRS A 3D9:.;=:}iEXTERI OR 1LATH : ` fsloB)nn�as.), � a NURANCE t -LATH- mat,section'ne<J nbe completed fermi is foronhundred dollars 311 ' ._....._ SCRATCH COAT ' _ 313=:.- -ROOF- NAIL.:._ ,hall n I` ,f Nat N pe f f tit k f hich,h perms' d 1 - -- - °I aY° i vzb' t'a`ct W n 501 - FINAL ELECTRICAL' IENERGY` Go pen .,Applicant502 ..FINAL. .PLUMBING ENERGY_--.--. _ _ - .NOTICE O PPL eamen at Exemption,yo should 503 - FINAL MECHANICAL ENERGY O z beemaes b�ec 'itWo hsCO pe , p of the Labor Cody umust revoked. Z � °Y h ° s ons.O N pe. . decried _ __-__..504_- FINAL BUILDING ENERGY F co\sTRUCnorvLEVDwNCY aAshall)CE - 505 - FINAL ELECTRICAL - -- - leadingI hereby affmt,h,N a c not , n 'ag y f«'fie perfOrma'nce the .k far which this P a .,.,peas 309] Civ.Cj . .---50.6 - GAS TESTO lid Name . - . Z '. .Address-• 507 FINAL PL UMBING - -.' - --....-- ._ ._... . ._.... - . IcenifyNaJh ad,hisapplict nawe��,.m.,N bovemro,madoni: 508 - FINAL MECHANICAli ' F CO act Is g¢e to comply with all city and county ordinances and state ren e laws ting 509 - FINAL GRADE �:'O:.V to bit ilding mnamcuon.:md hereby dulhoriee'represvntitines of Nit<hY merrier uPan inti b t J 510 - FINAL PLANNING [}.'0'•. O g ion prop rtY fy°cdk pha�rmll sNe C,y fClpcn o'Sg inn U Z c°baction.agso p Ithi which y any y < B;n., ,;,1 514 - FINAL PUB C WORKS APPL Ati VDe t$ r g rA-ILLermit COMPLY WITH ALLN NT �� SOUR . ?: ate-'.. Re-roofs ,'„ A US MATERIALS DISCLOSURE upPli oto reb ilding Occupant store or hadlehzdrdUsm:snit Type,of Roof.. ..... .......• as d,'!tiedby.theCpertrm tic paIC OJ Chapter912 and the Health and Safety "" •-� ++ Cad 5 t n2551_la� ` - :.G1 ,u "ri'•v`f ��.�`i t 4 1 , t tt.. ... ......-._...._....... All roofs shall be-inspected poor to any roofing material being Installed, Will the air t rim b 'IdNg« e Bt e.Ai ,o ae _ wnm If a roof Is mstalled'wi[hout firs[obtaining an inspection, Pagree'to remove smith d it col :notes defined by NeBUY AmA a I Management District' all new materials for inspection. Applicant understands and will comply with: ❑Y. ... ❑No - .. - all non-potnCsource regulations. -- '1 ha read.Ne h out sato al 505:relents d25 Chapter,1un6.95 OL,he 'torn.ingd sSafe oac.live .nount.dal it 1ocipa31.I.undersmnd Na, 'i H o;lding d s , ave a mnNo me,l i,s my meponoiof. a nmian arc - - --- -- - -- m the ,.,bit nun be ma prior m issuance of a <rtificac Of t - '- , cu rt noon - . .._... DL _._Signature of Applicant roof coverings [o be Class Date Ow, r amn tae a All Oamor)'titter .._. _ -..:. . . . .-OFFICE ..