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CITY OF CUPEWrINO
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BUILDING DIVISION PERMIT
{CONTRACTOR
INFO ATILT:®
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Bulb 0rsN BLANEY BLD 5991
PERMITN4@2060146
VAxOyINFIC GAS AND ELECTRIC CO
APPLICATI9VYB2JATty'2002
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IIONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
thereby affirm that l am licensed under provisions of Chapter 9(commencing
STRUCTURAL
Crl UOn
UPG1� P
with Section 701aB of Division 3 of Ne Business and Professions Code. and my license is
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In full force and effect
T.I
NEW BATHROOM ICE
License Chixx
lM RRILu
Ai"4 IEw tioN
Cmar
Date G
S DELL
DECLARATION
As
I understand my plans shall he used as public records
shall Wuse
JUN 1 12003
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby afford that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7131.5, Business and Professions Cndc: Any city or county
1 1
�Y I g'y
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which requires a Permit to construct. eller, improve, demolish, or repair any structure
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prior In its issuance, also requires she applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Conia lms License Law (Chapter 9
Sq, Fl. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Cod.) it
31603045.00
Nat he is exempt therefrom and dm basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of
not more Than fins hundred dollen DWI.
101
— FOUNDATION
❑ h as owner of the impony, or my employees with wages as their sale compensation,
Required Inspections
will do she work, and the structure is not intended or offered for sale (Sec. 7044, Business
Code: The Conuacror's License Law does
and Professions not apply to an owner of
103
- UFER
property who builds or improves thereon, and who does such work himulf or through his
own employees, provided that such improvements am not intended or offered for sale. If,
104
— REBAR t
however, the Wilding or improvement is sold within one yser of completion, the owner-
lOS
— ANCHOR BOLTS
builder will have the burden of proving that he did not Wild or smpow, for puryou of
ml=> I 1
106
- SEWER & WATER
as owner of the property, am exclusively contracting with licensed contractors to
2 02
- UNDERFLOOR PLUMBING
o suuct the project (Sea 7W, Business and Professions Cade:) The Contractor's Li.
Genu Law does not apply to an owner of property who Wilda or improes thereon, and.
203
— UNDERFLOOR MECHANICAL
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
204
- UNDERFLOOR FRAME
License law.
❑lame. underec. .B&PCforthisreason
205
- UNDERFLOOR INSULATION
Dam
301
- ROUGH PLUMBING
O KE 'S CO ENSATIONDECLAR TION
302
- TUB & OR SHOWER
I hereby affirm under Penalty of perjury roar lowing declarations:
383
— ROUGH MECHANICAL
❑ I have and will maintain a Certificate ofConsens to self insert mifm Wmku,ACompen-
son, a .video for by Section 3700 M the labor Crude.Ne e. for performance of the
304
— ROUGH ELECTRICAL
work far which this Permit is issued.
3055
— FRAME
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
306
- HOLDOWNS
3700 of the Latin, Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
307
— INSULATION
Carrier: Policy No.:
308
- SHEETROCK
CERTIFICATE
COMPENSATION EM PTION FROM ORKERS'
INS RANE
309
— EXTERIOR LATH
(This section need not Mcnmpleteddthe permit is l ivone hundred dollars(EIW)
310
- INTERIOR LATH
or less.)
311
- SCRATCH COAT
1 certify that in the performance of the work for which this permit is issued, I shall not
313
- ROOF NAIL
employ any pe i �s neo . tecomesubjeel c oration
Lawaaf Celi I —
501
- FINAL ELECTRICAL ENERGY
n,
APPlicant
502
- FINAL PLUMBING ENERGY
N I APPLIC T: IL a cr maki this Cenilicem of Exemption, y
p you should
su3ccuo the Worker's Compensation provisions of the lahor Code, you must
E
503
- FINAL MECHANICAL ENERGY
with comply with such provisions or this Permit shall be deemed revoked.
504
- FINAL BUILDING ENERGY
CONSTRUCTION LENDING AGENCY
C
I Warbyathom that dere is l consuunion lending agency for penormane.f
505
- FINAL ELECTRICAL
the work for which this vermis is issued (See. 3097, Cu, C.)
LenderName
N
NameAddress507
506
- GAS TEST
- FINAL PLUMBING
a
Lender's
I cenify that l have reNdor application end ante that Be arrow i.1...lion is
508
- FINAL MECHANICAL
mnect. 1 agree to comply with all city and county ordinances and shim laws relating to
5
FINAL GRADE
Wilding construction, and Earthy authorine representatives of this city m enter upon the
above-mentioneJproperty for inspection purposes.
rfl0
— F I NAQ PLANNI G
(We) agree to save, indemnify and keep harmless the City of against against
judgments, forms and expenses mit. may in any wayattmc against mid City
in
Aconsequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON -POINT
p
5
Issued by:
N U LI WORKS
Date
SOURC RE UL 10 S.
Re -roofs
r rcofA n onuan Data
HAZARDOUS MATERIALS DISCLOSURE
Type Of Roof
Will the applicant or future building occupant store or handle hazardous material
defied by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
e. Section 25532(.)1
All roofs shall be inspected prior to an roofing material being Installed.
P P Y 8 g
❑Yea afllNo
If a roof is installed
without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hannhous air contaminants as )coned by the Bay Area Air Quality Management
all new materials
for inspection.
IJislrict1
❑Yes No
I have real the hamodoos materials requirements under Chaphir6.95 of the Califon
m.Heal" SaferyCork, Sections 25505,25533 and 25534.1 unJmshinJ dray ifthe Wilding
does not currcn0y hats a tenant. Net it is my responsibility in notify tiro rccuPwi of the
rcqui cmawhi mus 1primmissumceofaceABcamnfoccup eY.
Signature of Applicant Date
OZL
"B"
All roof coverings to be Class or better
ermiu minds nl Date