03030024 B:CITY OF CUPERTINO
BUILDING DIVISION PERMIT
_DINO ADDRESS: DREAM HOME BUILDERS PERMITNO.
NEWS NAME:, 13675 LONG RIDGE . RD 'BR"'r"%�DA78
JON CROCILETT
ONE: (408) 781-1400 - SANITARY NO. 2 CONTROL NO. -
ARCHITECUENOMBER: BUILDING PERMIT INFO
BLDGO O PLO MECH
3Op LICENSED CONTRACTOR'S DECLARATION IbDIIOn
1 hereby offer NOQSCIIP
al 1 em licensed under provisions of Chapter 9(commencing
With Sm0on70f0)ar Dlvlalen 3afdw B.Mmet, ed�mlom Coca.md mylicenr"is
I"r°Il t°'«`^d IT !. REVISION--IN HOUSE USE
III---
U" 16 C n Luo�l POST/CB DETAILS @ ENTRY, NO NEW PERMIT ISSUED
3 Q ARCHrmCrSD ON
$9 ty7 ntendmypleneahallMmedupuoR wmrN ��l ORIG. #02050043
5� Licensed Pmfenioml .
Oat I am except
DECLARATION
+� 1 masa .(nrm the 1 1. uusin from the ConteProfession
License law for the
`oo following mason. emits 7(DL5,Bm1i e, and ver,dcrans Co de:Any Nly or caumy
12 whichitsIssuance.
requires a permit re cnwwn,alter, dforse,h Permit t of repair any structure
Astpoor
he its a sed pursuant
requires the afflicted fm Comma Permit to ice seL w(Chapter
t��y< (Ounce is initwiit pSwim lolhepmvidons 3 An ConusetmYlJamel+v(C Code)ca Sq.F[.Floor Area \ Valuation
t� thammexempt
Swim]Op)of bull for
the
the Bed axe Mon.Aral=CoCe)m v
33 Ihet heels"tempi Ucwfwm and the bull for the alleged exemption.Any vi"ledan of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occup$1@y Type
not mow than five hundred dollen(S5001
C 1,u owner of An prapany,or my employees with miles as deb wk cnmpenvdm,
will do the work,and the structure 1,not Intended m offered fm age(Sm.7044,Business
end Professions Cade:The Co"usmfa License 4w dual trot apply w an owrw of Required Inspections
property who builds mimprowsthemen,and whodasamh workhisem for thmuSh his
Own employ=,provided that such Improvements are not intended ornllcmd fmnle.If, 101 — FOUNDATION
however,the building or Improvement Is mid within one year of compledun.the owner.
ba8am w10 have the burden of paving that M aid not build or Improve for purpose of 102 — PIERS
"le*' 103 - UFER
0 1,as owner of tie property,am"elusively conuscting with licensed coevacwrs to 10 4 — REBAR
construct the project(Sec.7011.Bwlneu and Profculuns Cade*The Commamfs U•
came law d=not apply w an owner of propel a Will"m Improves f.,and, 105 — ANCHOR BOLTS
wM contrera for such pmjeeu with a conuac dix mwAscommemea
Lexam" 106 - SEWER & WATER
❑lama tno or this 202 - UNDERFLOOR PLUMBING
WORKERS COMPENSATION DECLARATIONam
203 - UNDERFLOOR MECHANICAL
I hereby alnna under penally of perjury one of the following declarmlons: 204 — UNDERFLOOR FRAME
C1have And will realnuln•CeAOcate of Consent to wl6lnsum for Workees Compen• 205 — UNDERFLOOR INSULATION
setion,M provided for by Section 37M of the labor code.fm An performance of the 301 — ROUGH PLUMBING
work for which this permit B issued. 302 - TUB &, OR SHOWER
C 1 haw and will maintain Worker's Compensation Insua=,as required by Section
3700 of the tabor code,ler the performs"c""f the work fmwhich this permit is rued. 303 — ROUGH MECHANICAL
My workers Compensation Insurance carrier and Polley number sac: 304 — ROUGH ELECTRICAL
c.Mal: Policy No.: 305 - FRAME
CERTIFICATE OF EKEMPnON FROM WORKERS'
COMPENSATION INSURANCE 306 — HOLDOWNS
(This Action need not IN,cmapleted if ale Permit is foram hundred dollars MIOD) 307 — INSULATION
meat`) l 308 - SHEETROCK
I certify dun inormance of de work fm w Ich this
Permit
ts Wued.I dull not
employwype iloans man gs berm eta de wmamF%cL;rt'tian 309 — EXTERIOR LATH
win CAlifa a.Dat 310 - INTERIOR LATH
N TO 1, dl this Ceniiewte or Exemption,you should 311 — SCRATCH COAT
Mneme subject w the Wo C"mpewdon provisions of the latter Cade,you most
.JO forthwith comply with watt providers or this permit mel be dmmed revoked. 313 — ROOF NAIL '
vv CONSTRUCTION LENDING AGENCY 501 - FINAL ELECTRICAL ENERGY
p. Ihereby AMM that them baconstruction lending agency for the performance of 502 FINAL PLUMBINGENERGY
fY' the work for which this permit is Issued(Sm.3097.Civ.CJ 503 - FINAL MECHANICAL ENERG
W Q Lender's Name
�z nde^A°°e" 504 - FINAL BUILDING ENE
UoF 1=try that IMwread this applicnlonand mmthat ft Wvc Information is 505 - FINAL. ELECTRICAL
D.U corral.I agree Io comply with all city and county Ordinances Aute
and laws Feeling to
0 building construction,and hereby authorize nnpresentstives of this city to enter upon the GAS EST
W st.memmand property for Inspection purposes
(we)agree torm
save,indemnify and keep hsku the City of Cupertino against 07 F I N
GLol 7 liabilities,judgments,corn and expcmes w5ch may In any way amu"against said City 5 A ICAL
U F7 In consequence of the Sm it of thi pe L
AP LICANT UNDERSTAND ILL COMPLY WITH AL NON-POINT Issued by:5 Date
5 L TIONS. I _
qS9Vo APPhc; ammeter Daw Re-roofs 5,.4 biU
- INAL PUBLIC WORKS -
HAZARDOUSMATERIALSDISCLOSURE Type of Roo
WIII the applicant or future building occupant more or handle hrnrdou material'
as defined by the Cupertino Municipal Code.Chapter 9.12,and IM Health and Safety
Section 255334)7All roofs shall be inspected prior to any roofing material being installed.
CYu
Will the applicant or future building occupant on equipment m devices whore If a roof is installed without first obtaining an inspection,I agree to remove
emit hazadnm air contaminants u donned by the Bay Anne Air Quality Management all new materials for inspection.
Duulc@ '/
CYcs G
Ihavci ullheluudousmaterlals rcyuimm t+y edam Chapter6.95orde Califnp
"Ie HUIIh65arelYCod ecd=2(5115.35573 3y3q.luedantend dot irthe building
d=not a "rely h en.4 that R b re r9 Ihlllly b eosins do oceu t of the
requlmmcu Irl melpr rb sCatifteateof tan Signature of Applicant Date
nermwtMr>cdagent All roof coverings to be Class"B"or better