03020124 FBUILDING
Y OF CUPERTINO
UILDING DIVISION PERMIT �kl.. L\.dl1LLVTQ1r �1�.M0
ADDRESS: C. SMITH PERMIT NO.
937 BROOKGROVE LN 03020124
'S NAME: PERMIT ISSUE DATE
!TEPHEN C. SMITH 02/28/2003
E: SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMITINFO
BLDO ELECT PLUMB MECH
�oo LICENSED that
CONTRACTORS DECons of CON Job Description
1 ion 7 affirm Nal l am Nunted under pmvialau of Code. 9(commencing p
in with Section 701f0)of DiNsian3of Ne BualnescaM Professions Code.and mylicenum
L1fmuerceend ertem ADD 100 SQ. FT. /REMODEL KITCHEN/ENTRY
5 Datenw Clue Dc.N
L DiLL' Contractor
p
ARCHITECTS
DECLARATION
[understand my plans Shall M used as public rocnrds
3 �a Licensed Prolong oul
3 Oat I am empt fr DECCom ON
i F I hereby.(Sect Net 1 1. exempt from also r Conuactoo :Uccnwmy
law for the
a p O following recon.(radon]851.3,B.She, and veressiuu Cade:Any city or manly .
$ which reauires• -Man po ennnnct,alma impmw,demolish,or repair any awn cut
F i^ palm m its mmence,aim requiree Nurvisw sof foe Com Penni'w im w Law(sutement
< thstheis encinS edpursuant mM)ofDivision3nf cSWingstUniavelaw(C cele)9 Sq.Ft. Floor Area 'on
that he Is ng pt SectionTOM)and Mr Division 5nf1Meged exe anion.An vi Corte)ur
Nat he h esemp'therefrom and Ne bum tender alleged exemption.Any v1o1N6n of
Section 78513 by any applicant for a permit subjects Ne applicators or a civil penalty of
not more than five hundred dollars(5500). r Occupancy Type not
1.u owner of the pmpwy,w my employer with wages u dale sole compenutlon,
will do Ne woe:,and the structure is not intended oroffered fmstle(Sec.IBIS.Business
and Professions Code:The Contmmn Limme LAw dean not apply w an owner or 102 - PIERS Required Inspections .
Property who Wildsorinnrowa Nerenn.and whotlaessochworkhimsslfor though his
awn employees,provided Net Such lmprovemmu are not intended waffmed(wale.IL 103 — UFER
however.Ne building ardmprowmmfiasolt didnor Sear of Improve
purpose
of 104 — REBAR
Wilder will haw'he barmen of pmWng Nn ha did rot Hood a ImPww for purposu of
"Is.). .10 5 — ANCHOR BOLTS
❑1.as owner of the progeny,am exclusively cantrscting with licensed cormutrs an 106 - SEWER & WATER
construct the pmjec5(Sm,7044.Business and Professions Code:)The Contracmh LI-
centsLewdoesnoupplyheanownerorpropertywhobuild,or improves lhereon,and, 202 — UNDERFLOOR PLUMBING
who contract for such projects with a contractor(s)licensed pursuant te the Contractors 203 - UNDERFLOOR MECHANICAL
emu Law.
l am exemp'u der Be
,B&P C for this mason 204 - UNDERFLOOR FRAME
m z4 O 205 - UNDERFLOOR INSULATION
RK COMPENSATIONDECI.A N 301 - ROUGH PLUMBING
l hereby alarm under penalty of pedury arc of the fallowing declarnioce 302 — TUB & OR SHOWER
❑Ihaw and for
by eCWeamef Cauemmcm&,rumforWorkeh Compere- 303 — ROUGH MECHANICAL
orlon.u provided for by Section 5700 of the IaWr Cade,fm Ne perfarmanm of she
work for which NH permit is issued. 304 - ROUGH ELECTRICAL
❑1 haw and will maintain Workers Compensation Insurance,as required by Section 305 — FRAME
7700 or Ne Labor Cedo,for the performance of Ne work for which this permit Is Issued.
My Workers Compensation Insurance ander and Policy number am: 306 — HOLDOWNS
carver. policy No.; 307 - .INSULATION
CERTIFICATEOPPENSATION7INSURANCfioRKERs' 308 - SHEETROCK
('Drs semen coed not Wcompleted ifthe Permit mforom hundred&Ihua(SIM) 309 - EXTERIOR LATH
cele") 310 - INTERIOR LATH
I certify that In the performance or the work for which this permit i,Issued.I shall not 311 - SCRATCH COAT
employYtS'person ift manse an u he become wbjen m the Workers'Compensation
Lsw, nfomie c6 313 - ROOF NAIL
Applicant
NOTICE? PPLICANCIf.after making this Certificate ofExemption,you should 501 - FINAL ELECTRICAL ENERGY
become sub ret10the Worker,Compensation previsions of the labor Cade,you must 502 - FINAL PLUMBING ENERGY
0z forthwith complym
with Such provisions or this permit shell be deemed revoked.
z O CONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL ENERGY
p.� l hereby arrnm that them IS coutnmdmn lending agency for Ne performance of 504 - FINAL BUILDING ENERGY
x� Ne"a for which this permit isIssued IS=3D97.CN.C.) 505 - FINAL ELECTRICAL
W Le tubes Nurse
DLendersAddreu 506 - GAS TEST
UO 1 ceniry thatI have rad Ns Application and slim Na'Ne above Integration I, 507 — FINAL PLUMBING
Ig, E crenalagreemcomply with all city and county ordinances and Smac fiate,relatingfo 8 - FINAL MECHANICAL
O building construction, d hereby authorim mpctemadves of this city to enter upon Me
`, W ahovcmmrnnd propcny for Inspection PuPosua 5 O — F I L GRADE
�,•t^Ty in gone m saw,led cmnify and keep humleu the City or Cupertino against
ti f/1 Ileblllldea,Judgment,cow and expenses which may in any way accrue against aid City 0 1 P NG c
U F2i APPLICANT UNDEof the RSTANDS ANDof WILLWILL COMPLY WITH ALL NON-POINT Issued by: 5 C WORKSDate
SOURCEREG ON
3 Re-roofs
79tvarlinofApp HAZARDOUS MATERIALS Dam Type of Roof
Will the applicant or future building=upset stow or handle huudms material
U de0ned by the Cupertino Municipal Cude,Chapter 9.13.and the Health and Safety
c e SectiP tics eousSz(°)7 All roofs shall be inspected prior to any roofing material being installed.
�No
Will the applicant or future building occupant use cyulpmenl at devices which If a roof is installed without first obtaining an inspection,I agree to remove
melt haeameu air cenfamdunn as defined by the Bay Am,Air Quality Management
Dinrdct7 all new materials for inspection.
❑Yea Pd No
I hew rem the huardmsmwralsorrubcomms underChap criL95of the Califor.
nil Health&Salcty Code,Sections 25505.35575 and 25534.1 undimmed that ifdt Wilding
0ti
ars not currently hew So tenet.Net It u my respoulAlllty b turfy do occupant of Ne
rcyulreme hmug bemetpriormluuumofaCcolicamaTeap�,,rccy. Signature of Applicant - Date
� _ � 24 0; All roof coverings to be Class"B"or better
wncr or authlificteda c Date