03020057 CITY OF CUPERTINO
..BUILDING DIVISION PERMITONA�'f1R INX<'O,YtMA.'Y' Ol : h
BUILDING ADDRESS: ALAN STOCKLMEIR PERMITN°.
ZFELAN
NAME: PERMIT ISS A
SANITARY 11.;3 H04iOLNO.
ARCHITEC IENOINBER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
yY00 LICENSED CONTRACTORS DECLARATION JobDescription -
ti 1 barony of inn that I am licensed under remains,of Chapter 9(commencing
with Salton 70M)of DlvWan 3 of the Busineu and Pmteuhln Coda.and my license is .
j1 mmua
faeandarte REVISION ONLY
E
uaanw clue Lk.R
IN °ate ARCHI7ECTSDECLARATION ORIGINAL PERMIT #02050104 <�
°�f 1 understand my plan shall be,wood u public menrN k(�
k W Na Licensed Professional v
OWNER.BUILDER DECLARATION
1 hereby arron that 1 am exempt from the ConlrutaYa License Law for the
o o following reason.(Section 70313,Business and Professions Code:Any city or county
$ which requires a permit to mtnnct,afar,hormone.demolish.Or repair any swcmrc
-z ' prior in its issuance.atso mqulmi the MPlluntfn anch Permit to file•alined statement
< wodheislicensedpwrasolOnweprovisionsorthecontractwsUmmeLaw(CMping Sq.Ft.Floor Area Valuation
$ (commencing with Section 70)(1)of DiNeion 3 of to Business and Pmfculoos Code)ce
that he Is eompt thcrcfrom and do basis fu the alleged eumpBan.My'low.of
Section 703 1.3 by any applicant los a Permit subjects dm APPlkanl to a CMI penny of APN Number Occupancy_Type
not more dun 0w hundred da1W(g5D04
❑I.as m nu.rum property,or my employes with waist as their solo coma unan. 35606034 . 00
will do the wort.and the strcen ewrens
omum isneat intended oraffercd for safe(Sec.7044,Business Rid Inspections
w Pmfeulan Code:The Commusnes Lkm Law does not apply m an awnor P
pmperywho bulldsorimprovu Wemomand whodoetauch work himWror though his 101 - . FOUNDATION
crop mldoyees,pmmdedthatwchimpmmememsarerelrammednarteredforads.B. 102 - PIERS
howemer.wa bmilding o,impro.con H sold within ane yen oreonpkdon.the ownn.
buildn will Nom do burden of IMMWZ dal be did rel Wild or Improv for purpose of 103 - UFER
ask')' 104 - REBAR
o I.u conn or the property am uc)uaiwly connecting with licensed c mmosten in
construct the project(Sec.70m,Business and Profusion Code:)The Cmmamr'a Ll- 105 - ANCHOR BOLTS.
cane law does not apply to an owner of property who builds or lmprnvv thereon,and, lO6 - SEWER & WATER
who contracts for such projects with a eomwumrls)licensed pursuant m the Camrxtota
Llaase Law. 202 - -UNDERFLOOR PLUMBING -
IeaemptunderSec .BA PC far Wareamn
203 - UNDERFLOOR MECHANICAL
Dow
WORKER'S COMPENSATION DECLARATION 204 - UNDERFLOOR -FRAME
Ihereby affrtm under penalty of perjury one or the following declaration: 205 UNDERFLOOR INSULATION
w and will maintain a CertlBcmem'Commot to self-imum fnwodmr'sCoupn- 301 - ROUGH PLUMBING
asprovidedfan by Section 370°of to Labor Code,Tor the performance of the 302 - TUB & OR SHOWER
r which this permit Is Broad.w and will maintain Worker's Compensation Insurance,as required by Section 303 ROUGH MECHANICALthe LaborCOEe.forthe performance of to work for which this Permit la Issued. 304 - ROUGH ELECTRICAL.rkers Compensation lnannnce carrier and Policy number am: 305 - FRAME "
Center: Policy No.:
CERTIFICATEOFEKEMPTION FROM WORKERS' 306 - HOLDOWNS
COMPENSATION INSURANCE 307 - INSULATION
Crisis mctotneed Out boaompleedinheparoltlsfnonehumdreddollars(SIM)
micas.) 308 - SHEETROCK
- -
I certify that In the performance of the work for which this permit Is Issued.I shall not3 O J - EXTERIOR LATH
employ any person In any mannerso as to become subject a thewarken'Coopcomton 310 INTERIOR, LATH
Laws of Calffomia.Dau
Applicant 311 - SCRATCH, COAT
NOTICE TO APPLICANT:If,after making this CurilRCate of Exemption,you shnulE 313 - ROOF NAIL
become subject m the Worker's Compensation provisions of the Labor Code,you most -
'Jp forthwith comply with such pmNatan or mix Permit hall be deemed mwked. 501 - FINAL ELECTRICAL ENERGY
CONSTRUCTION LENDING AGENCY 502 L FINAL PLUMBING ENERGY
Thereby M.that Ilam H acemotedon lending agency for 0.performance of 503, - FINAL MECHANICAL ENERGY
r4 the work for which this permit Is issued(Sec.3097.CO.C.)
W Q Lenders time 504 - FINAL BUILDING ENERGY - -
a Lender's Addm»
UC 505 - FINAL ELECTRICAL
IceNetut1haw mad and county
and ma thst the abovews resting Is 506 - GAS TEST
r'. correct.1 agree to comply with all clay and county Minanas and suss laws s upon the� building construction,and hereby anthodse rcprcsenmlmesaf Nb clay to units upon ire FIN PLUMB G '
Laid above-menliored properly for Inspection purposes.
G (We)agree m same,indemnify and keep harrnles,the City of Cupertino against 0 8 F I L
,.y N liabilities.judgment,costs and expenses which may In any way aaruo against mid City
of the
of
V in APPLICANT UNDERSfAN0S1his AND WILL COMPLY WITH ALL NON-POINT Issued by:5R INrmit. 5
G Date
SOURCE REGULATIONS. Re-roofs 514 NAL PUBLIC WORKS "
Sigraurcol'AppltcentCanuecmr Dar E2p2 - OOF PLYWOOD NAIL
HAZARDOUS MATERIALS DISCLOSURE Type of R`�'b0 "
Will the applicance
torfuture building aupantme m
tsorlandle hardous material 3 - ROOF BATTENS
ned by the Cupertino Municipal Code,Chapter 9.12.and to Health and Safely (04 - R00�' 'N-PROGRESS
Section0Y.2553$4)7 All roofs shall be ins ecce prior to an room material beim installed.
❑Yas ON. P P Y g g
Will the Applicant or mom calming Occupant nm equipment or devlen`whkA If a roof is installed without first obtaining an inspection,I agree to remove
I
trallous air commemants u dc0acd by tho Bay Area Air Quality Management all new materials for inspection.
t7
D Yes 0 N
Ihue mad to huardmsmaterials roquimm us underChapin6,93oftheCalifor
alth&SafnYCadc,Section25505,25533 and 25534.1 understand thstifthe Aiming
ot currently haw a tenant thst It is my responsibility m rmdfy the occupant of the
rcgmmmamawhich mum Is,melpdmmirnnsaor,cocrtmnorOccupancy. Signature of Applicant Date
Owner or authorived agent Dao All roof coverings to be Class"B"or better