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CITY OFCUPERTINOss.
BUILDING DIVISION PERMIT
WCONTRACTOR
INFORMATION ''.
Burl lu E BLD 6u:2
PERMITN(D2060148
1\/
a tlsCdrySft••:IC GAS AND ELECTRIC CO
APPLICATOVY"24rfr2002
"ONE.
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB
MECH
O O O
O
LICENSED CONTRACTOR'S DECLARATION
provisions of Chapter 9 (commencing
I hereby affirm thu 1 am licensed under and
with Section Division 3 o dac Business and Pn+fessinns Cnde, sad mylicenseis
Professions
SEI SMI C UPGRAd2 D��Ju MPL IANCE
to fens ICRC and cffca.
and
License Class Llc.g
'
Dam Connector—
ARCHITECTS DECLARATION
E
DECLARATION
1 undersmnd my plans shall he used as Public rca+N.e
Licensed Nol'essinnal
OWNER BUILDER DECLARATION
1 hereby .(firm Inas 11. exempt from the Contractor'sLicense Lew for the
115 O O O
following reason. anvas Code: Any city ns county
Ronstr Busincss and Professions
y�
permit i h,o
which requires a permit st construct, alma impose, or repair any structure
h parrot t
poortoi(s issuance.assn requites the applicant for suchpactor. Glnssigned summcm
the
that (Chapter 9
3Sb61R3RI(flbSAf.�®
Valuation
mencingwitpunuanUnth,ofDivinro 3she the
(commencing with Section ]lan) of Division 3 of the Business and
vi Calc) of
on. Any
Wt he u exempt themfrom and 0th basis for the Jlegcd exemption. Any violation of
iUAPNNWAj6aMATiUN
Occupancy T
P y yPe
Saturn 7031.5 by any applicator for a permit subjects the applicant to a civil penalty of
not more man five hundred doll.. Eky00n.
102 —
PIERS -
i,urwner of the property, or my cmplCyces wida wages as thea sole compensation.
Required Inspections
will do the work, and the structure is not intended oroffereN forstle(See. 7044. Business
end Professions Cash: The Contractor's License law does not apply to an owmr of
104 -
REBAR
property who builds or improves daemon, and who does such work himselfordarough his
own employees, provided Biot such improvements are not intended or offered for We. It.
105 —
ANCHOR BOLTS
however, the building or improvement is said within one year of completion, the owner-
106 —
SEWER & WATER
builder will have the burden of proving that he did not build Cr improve for purpose of
sate.).
202 -
UNDERFLOOR PLUMBING
, as owner of the property, em exclusively cocirtacting with licensed contractors to
203 -
UNDERFLOOR MECHANICAL
on Item the project (Sec. 7044, Busincss and Professions Code:) The Convector's Li
cause Law dims not apply to an owner of property who builds or improves therton.and
204 -
UNDERFLOOR FRAME
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors'
205 —
UNDERFLOOR INSULATION
License Law.
❑lam axes under Sec .B&PC for this reason
301 -
ROUGH PLUMBING
r QV 1, O43
302 -
TUB 6r, OR SHOWER
WfkMR'S•OMPI S TIONDECLAItAlION
303 -
ROUGH MECHANICAL
1 hereby affirm under racially of perjury one of the following declarations:
3 04 —
ROUGH ELECTRICAL
❑ I have and will maintain a Certificate of Consent to self -insure for worker's Crimper.
305 —
FRAME
union, M provided for by Scri on 37W of due labor Code, for the performance of the
work for which this Permit is issued.
306 —
HOLDOWNS
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
307 -
INSULATION
370() of the labor Coh, for the performance of the work for which this permit is issued.
My Worker's Compensation lnsumnce carrier and Policy number are:
308 —
SHEETROCK
Carrier: Policy Nu:
309 -
EXTERIOR LATH
CERTIFICATE
COMPENSATION INSURANCE PTION FROM WORKERS'
310 —
INTERIOR LATH
(Thu acerin. need not he completed if be Permit is fusion hundred dul.4100)
311 -
SCRATCH COAT
urlen)
313 -
ROOF NAIL
Irenifyth.tinthePe"r�form/gpaay�eeofthewmkrorwhichmispmitisi d.Ishaunnt
501 -
FINAL ELECTRICAL ENERGY
employe type. ngny,yn,c /}stere l� gr�SuYlCt t to the Workers'Compensation
lawsofcali teaTil'// /Ya IIr/�OLL
502 -
FINAL PLUMBING ENERGY
71 phcE� A PLLIC il�errm onildis-CC�icate of Exemption. youshould
�cs
503 -
FINAL MECHANICAL ENERGY
jecttome cr's Compensauonprovisionsofihe labor C.de,y0umun
504 -
FINAL BUILDING ENERGY
forthwith comply with such provisions or this Permit shall he deemed revoked.
505 -
FINAL ELECTRICAL
CONSTRUCTIONLENDING AGENCY
I hereby affirm mer marc iso construction lending agency for the performance of
506 -
GAS TEST
the work ]or which this permit is issued (See. YN], Co.C.)
ame
Leader'sAdddress A
507 -
508 -
FINAL PLUMBING
FINAL MECHANICAL
Lenders d.
I certify that 1 have read dais application and stat, that he ahoy information is
509 -
FINAL GRADE
correct, l agree to comply with all city and county ordinances and sure laws relating to
5
FINAL PLANNING
building construction, and hereby authorim representatives of this city to enter upon the
above mentioned properly for inspection purposes.
514 —
FIN BLIC W RKS
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities. judgments, costs and expenses which may in any way secure against said City
in consequcwe of the granting of this peit.
rm
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT
Issued by:
Date 3/
1
SOU - REGO ATI S'
Re -roofs
are malipplicantlContruselivir Dau
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or turn. Wilding occupant nom Cr handle haaardous material
defined by the Cup,nino Municipal Cork, Chapter 9.11. and the Health and Safely
e, SecoYCR 25532(4)] ON.
All roofs shall be inspected
prior to any roofing material being installed.
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 hasallous air contaminants as defined by the Bay Arca Air Quality Management
all new materials for
inspection.
District?
[]Yet 06+
1 have rend the humorous materials requirements under Chapter 6.95 of Bic Califory
nim l Icalth & Sufmy Calc, Soctionx 25505, 25533 and 25534.1 undershot that if the building
docs not cunendy have a tenant, that it is my reafonsihility to notify the occupant or the
requirem nts which m pe mW Prior m issuance of a Cenificate ocap.W4(4 MAo"i 110;ill
7-a
Signature of Applicant Date
All roof coverings to be Class "B" or better
,r or aunt ized ag n(