02100151CITY OF CUPER'rINO
'
BUILDING DIVISION PERMIT
M4CONTRACTORINFORMATION:
B,
u 191.)0441ED1kFaANSON AV
ALL SEASONS
PATIO ENCLOSU
]!gSMITN02100151
'R:a4A6HIK
219 DEMPSEY
RD
APPLICAT11OSpf2DPTf2002
/
PHONE:
(408)946-4744
SANITARY NO./ CONTROL NO.
ARCHITEC MNGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACT'OR'S DECLARATION
1 Mrebyofof malIam licensed underprovisionsPronnsofs
of hap 9
REVISION
ONLY Job Description
with Scetion ]IXXI) of Division t of the Business and Pndcssinnx Code, and my liccnst• is
Code, my license
in fallforeanJeffeet.
NO
NEW PERMIT ISSUED.
Damns erase Couto
Dale QS
ORIGINAL
PERMIT 02090083
DECLARATION ARCHITECTouse DECLARATION
I understand my Plunx sM1ull he used as public rcuah
Licensed Pmfessinnal
OWNER -BUILDER DECLARATION
1 hereby affirm mal 1 am exempt from the Conten o ., License law for the
following reason. (Section ]IH I.S. Business and Pnafcuions Code: Any city or county
which requires a permit ter construct, all improv. demolish, or repair any saumare
prior to its issuance, also requires the applicant for such Permit o Glc a signet uetement
that he islicensed pamumrIt) In, provisions ofave ComacmRLicense Law (Chapter 9
Sq.
Ft. Floor Area V Galion
(commencing with Section Mao Of Division S of the Business and Professions Cole) or
Into IW is exempt therefrom and the basis for thc alleged exemption. Any violation of
Section ]031.5 by any applicant for a permit subjects the applicant to a civil penalty of
be Occupancy Type
am more man five hundred dollars (SSW).
0 1, as owner of the Pmpeny, or my employees with wages as their sale compensation,
will do the work, and the structure is not intended or offered for sale (Sec. ]WX, Business
and Profusions code: me Contractors License Law ares not apply to an owner of
102
— PIERS egUlred Inspections
property who W ildsor imposes thereon, and whodres such work himself or through his
own employee, himpmomcnlsvene intended for Sorel,
ori
103
— UFER
BeeWildin proveoor
rimprovement isdaldwithinot year of completion, theowner
huilder
104
REBAR
will him
builder will have J¢ burden of proving Nat he tlitl not hui10 or improve for purpose of
—
sale')'
105
- ANCHOR BOLTS
O 1, as owner of the popcny,amexclusively contracting with licensed contractors tit
106
- SEWER & WATER
construct the probeL (Sec. 7144, Business and Professions Code:) The Contractor's Li-
c selawdresno,apply1. novo., ofprupertyWild,
202
/!'
who orlmpmvaathereon,aad
- UNDERFLOOR PLUMBING
who cemmcts no such pmjeces with a coribren r(e) licensed pursuant to me Connector'a
License Law.
203
- UNDERFLOOR MECHANICAL ��
O l am exempt under Sec. ,B&PC for this maven
204
- UNDERFLOOR FRAME /
fair Dam
205
301
- UNDERFLOOR INSULATION
H
— ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION
Ihereby efrrmunder Penalty ofperjuryOne oflbefollowing declaraend:
302
— TUB OR SHINER
❑mama and provill ded
Sarson, u proviJCJ for by Section 3]W of the labor Cole, for the performance of the
by eCmnf37W of Co Laborst,at to selfCode. for By Performance of en -the
303
— ROUGH MECHANICAL
work forwhirhthispentoisiested.
304
— ROUGH ELECTRICAL
0 1 have and will maintain Worker's Compensation Insurance, m required by Section
3 0 5
— FRAME
37(X) of the labor Code, for the performmme of the work for which this permit is issued.
My Worker's Compensation Insurance earner and Policy number am:
306
— HCLDCWNS
carie° Policy No.:
307
— INSULATION
CERTIFI O
COMPENSATION INSRACEORKERS'
308
— SHEETROCK
(TniascebonneeJnmmoomplmediflheperrroneandm
inufthde,dlarsRlan
309
— EXTERIOR LATH
or lC9s.)
310
— INTERIOR LATH
I eenify that in the performance of the work for which This p .it is issued, I shall not
cmPerson Peany manncrsoao s become strabeuth
oe Wmin,s Comachrouon
311
— SCRATCH COAT
Laws of California Dale
313
— ROOF NAIL
Applicant
501
- FINAL ELECTRICAL ENERGY
NOTICE TO APPLICANT:If. after making this Certificate of Exemption. you should
become Subject 10 the Worker's Compensation provisions of the Latur Code. you must
forthwith comply with such prodsons or this Permit Shan he deemed invoked.
502
— FINAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY
503
— FINAL MECHANICAL ENERGY
Ithereby amrmmalthen isaconnramionlending agency for the permrmam<of
504
— FINAL BUILDING ENERGY
the weak for which NCo, C
is permit is issued (See. 304], Ir)
the eName
505
506
— FINAL ELECTRICAL
— GAS TEST
leaders AJdmss
I misty that I have read this application and sun that me above information is
507
— FINAL PLUMBING
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authrour representatives of this city to enter upon the
5
— FINAL MECHANICAL
alwve"mentioned popcny for inspection parposcs
(We) agree o save, indemnify and keep harmless the City of Cupertino against
SO9
— FIN GRADE
seam lilies. judgments, costs and expenses which may in any way acerfc against said Ci ly
5
F N G
in consequence of the granting of Nis Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT
Issued by51
WORKS Date
SOURCE REGULATIONS.
Re -roofs
Signatom of ApphcaHAZARDO Dam
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building m handle ria ardour material
rstore9.1
Idefined Muni e, Chapter
the Cupertino Municipal Coble, Chapter 9.12. and the Health and Safely
io
We. Section 25532(al'!
r2 yes ❑No
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future budding Occupant arae equipment
pan qui for
If a roof is installed without first obtaining an inspection, I agree to remove
g P
emit hasardnus aircumaminanls as defincJ by the may Arca Air Qualify Managcmcnt
Management
Di.arict'f
all new materials
for inspection.
❑Yes CIN.
I have mad the haardous muterials requirements under Chapter 6.95 of the Califor-
nia Health &Safety CoWc.Stations 25AI5.25533 and 2553..1 un lcrsland thatitlhe Wilding
does not currently bare a tenant, mat it is my responsibility m notity me ocupanl of the
requirements which must be met prior to issuance of a CeniGcam of Occupancy.
Signature of Applicant
Date
All roof coverings to be Class "B" or better
Owner orMan ori..mdagent Date