03030070 CITY OF CUPERTINO -
BUILDING DIVISION P);RMIT rkl"'OVT1tA.(;TORI1VIt'UATO, N
BUILDING ADDRESS: PERMITNO. ,
OWNER'S NAME: PERMIT ISSU
PHYLLIS SIMPKINS IEe - SANITARY NO. OL NO.,
ARCHITECUENOINEER: - BUIIDINO PERMIT INFO
- BLDG - ELECT - PLUMB MECH
p 0 0 o 0
Yp Zp - LICENSED CONTRACTOR'S DECLARATION Job DI:SCrIpIIOn -
(� 1 hereby afar¢that 1 em licensed under powialow or Chapter 9(commencing _
with Sec,lon 9011 )azhrkion 3 of the Bud.."and Professions Code.and my licenmh
in full force and effect ADD GAS LINE TO FIREPLACE
is License Class Lic.0
Dais Contractor FINALE®
ARCHr1ECrS DECLARATION
1 understand my plana Mall M used as public mcmds
LicensedPmfeuional APR0 3 .2003
g OWNER-BUILDER DECLARATION
2 i 1 hereby afO,m that 1 am exempt form the Contractor',License Lew for the -
i o o following reason.(Section 703 1.5,Business and professions Codc:Any city or county 'BUILDING
$ which aqulre,a permit to construct,altar.Impmmm
,denitsh,or¢pelf any structure
-erg poor in its issuance.Also requires the applicant for such Permit file ulgned nAiement
a that heislkcn.dpmuemtANeprovisionsorthecontractor.Leon.law(chapter9 Sq.Ft.Floor Area $i/�l ton
(eammeaing with Section 7000)of Division 3 of the BOiness and Profeumol Code).'
Nat he is exempt tl.mfrom and the basis for the alleged exemption.Any violation of �
Section 1031.5 by any applicant for a permit subkou the Applicant to A civil penalty of 3APd Neft is 0 0 Occupancy Type .
not moa Nan Ba hundred out].($500).
❑I;ss owner of the property.or my employees with wage,u their tole compensation. TTq'+�
will do the work and On structureh riot intended¢offered for-to(Sec.70th,Business — WER RS3gdOlMi3ections -
and Professions Code:The Contractors Liam law does not apply to an owner of Oo
Property who bunds.,improve.theaon,ano who dauuchwork himsetforOmugh him 202 - UNDERFL OR PLUMBING .
own employees.provided that such improvements Am not Intended or offered fm Ask.It. 301 _ ROjJGH,. PLUMBING
"
hawevar,Ne building or improvement Is old within aro yeu ofampledon.the owns
builder will ham the human of proving that he did not build or Improve for purpose of 302 , — TUB tie OR SHOWER
mol`' 502 - FINAL PLUMBING ENERGY
�{as owner of site property,am welualvely contracting with licensed contractors to
c Wet the project(Sec.7004,Business and Professions Code:)The Contractor's LL 506. — GAS TEST - -
--law dew not apply m an owner of property who WIIN or improves thereon,and - 507 — FINAL PLUMBING
who contracts for caeca projects with a contsaenortO licensed punwnt she ConuAcwts
Lkan.law. . -
I am cxemmp-tinder Sec/�'� .B S:P C fo s rea.n
we f f f1.—._\
WORKERS COMPENSA�TIOI ECLARATION
I hereby affrot under pensliy of perjury as of the following declarAone.
h.w and will maintain A Car lnermaf Consent to melt-nsum fa Workers Compen-
utlon.a pavided for by Section 3700 of the labor Code.far the perli m ence of the
worts for which this Permit is Issued. -
❑1 hem And will maintain Workers Compensation Insuana,At required by Section
3700 of the labor Code,for 0w perfmmaa of the work for which Of.permit Is issued.My Worker,Compensation Insurance carrier end Policy number aa:
carrier. Policy No.: '
CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE - -
(This sa0on need Am he completed film permit B forowhuadaddollxra(SIM) -
I modify the,In the perrormance of the work for which thla permit Is Issued.I"I not -
emplayanypenspp��a�3�menwr.asNbco Je it he W.herf Compandon. -
Laws 000f,(.Cal 1f.mI1,DHe �
Appla�4 �� 4 - ..
NOT TO APPLICANT:If,after making this nificate of Exemption,you,hadd
become subject to the Workers Compensation provisions of the Lahr Coda.you must - -
.,O foMwith amply with much provisions or thio permlWnll be domed moked.
- CONSTRUCTION LENDING AGENCY
(~ I hereby affirm that thea ka commuction lending agency for the performance of -
Yi the work for which this permit is luueo(Sec.3097,CO.C.) -
W Q Lender.Nem'
=z lander',Address
U Q . I mo fy that 1 ham mad this application and state that the above inknon.000 1,
V. comet.I agree to comply with all city and county ordinances and state laws totaling to
0U building construction.And hereby material representatives or Nie city to enter Upon the
W Abovcmentioned prepay for Inspection purposes. -
(We)agree to move,Indemnify and keep harmless the City or Cupertino Against
zyliabilities,judgments.costs and expentw which may in any way aa,a against said City
U APPin LICANT UNDEof the RSTANDSof iAIND WILL COMPLY WITH ALL NONPOINT Issued by: Dale -�
SOURCE REGULATIONS.
0 711e-roofs .
urc of AppllunVContoctor DA/
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the Applicant or future building aeupantawa or handle hmwdous materiel
oenncd by the Cupertino Municipal Code.Chapter 9.13,and the Health And Safety
We.Sad..25532(.)7 /° All roofs shall be inspected prior to any roofing material being installed:
❑Yee _
Will the applicant or future building Occupant use equlpmem or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It h t ardous air contaminants u defmod by the Bay Arca Air Quality Management all new materials for Inspection.
inrict7 y.
❑Yes
I how mW do tonadnusmawriAlsrequimments under Chep or 6.95 of the Celifo.
as
InN Hal"Sahly Cock,Scetimu 1550d 25
5.25533 And! I unhoaano thB ifthe building -
dee not curan0y Mw a tenant,Net it is my rcapowibilily At notify th<scup.,of the
requirements which must the met fulor las Issuance or.CcdOca .f Ocaapenay. Signa lure of Applicant Date
'� 3 ` All roof coverings to be Class"B"or better
Owns .0 hmlad agent ate