02120041 CITY OF CUPEATINO "
BUILDING DIVISION PERMIT C0NTRACTOMFORMATI ON .
. an R4. -
SUILDINGADDRFSS: - % PERMITNO.
02120041
N M PERMR ISSUE DATE
05/23/2003
SANITARY NO. CONTROL NO,
A0.CHITECTIENGINEE0.:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a a a a
00 LICENSED CONTRACTOR'S DECLARATION Job Description
C 1 herchy affirm that 1 am licensed under provisions of Chapter 9(commencing
iiwith to=701p)otDivision Sof dm Business and Profcuiov Code.and mylicense is
in full ctio andeffect.
q'=
Licemse Class Lic.11 ADD 642 SQ. FT.
t;a Dam Contractor
pp ARCHITECTS DECLARATION
or< I understand my plans shall M used as public records
5aV
s o Licensed Professional /
S OWNER-BUILDER DECLARATION
1 hemhy a?nn that 1 a.1. exempt from the Canons c c:Any c Lew for the Jn�
p o which
followingmoon.a Permit
IIu to Business and improve.
dioov Code:Any oily or country <
,2
which inquires a issuance.also m inns the
tlter,improv,h Permit t fi repair any swcuin
azi that Wits ensedalsarcyuitcuhevisiosofcant for sucContrcrmitmicensle ae ned Law(Chapter
£i< Chatmecingwiit Purstion 7 )of Division
of the tantrums aLiccnulaw(ChaPmr9 Sq.Ft.Floor Area Valuation
teat he of
(commencing therefrom
and of Divixiof r of the alleged
exemM on.Anynvi lat on of
,59 tNt he u exempt tMxfrom and the buts for the allegrA exemption.Any violation of
Secret 7071.5 by my applicant for a permit subjects the appliaot to a civil Penalty of APN Number $2 cyMUacy Type
not mom Nan five hundred dollen(5500).
❑1.or owner of the property,in my employees with wages as their sole compensation,
will do the work and the swctum is not intended or ofcmd female(Sec.?044,Business
and Protestants Code:The Convectors Liceree law does cat apply In an owner of 36921024 . 00 Required Inspections
pmpeny w ha builds a i reproves thereon,and who daasuch work himael f or through his
ownemployees.providedaratwehimprovementsaxnotinmM mOffcMfmsale.If.
hawcwt Nebuildingorimpmwmentiswidwithinomyeuofcompledon.theowner- 101 — FOUNDATION
Wilder will have the burden of proving that he did not build or improve fm Palo.of 102 - PIERS
sale.).
❑1.as owner of the property.am exclusively contracting with licensed contractors to 103 — UFER
conswet the PMjcct(Sce.7044.Business and Prnfatov Code:)The Contractors Li 104 — REBAR .
ave law dine not apply in an owner of property who builds or improves thereon,and
who contracts for such pm)ects with a convachn(s)lianed pursuant to the Cunei 105 — ANCHOR BOLTS
Licerec aw. 106 - SEWER & WATER
0l am exempt of Scc. B&PCfor ad,
f( l L d
w3, 202 - UNDERFLOOR PLUMBING
WORKER'S OMPENSATIONDECLARATION o n 203 - UNDERFLOOR MECHANICAL
I hereby affirm under penalty at perjury rete or the following aeclantmn: 204 — UNDERFLOOR FRAME
I mw and will maintain a Cenioate ofcommad to self-insure mrwerkar'sCompen- 205 — UNDERFLOOR INSULATION
..can,v provided for by Section 3700 of the labor Code,for the performance of the 3 O l - ROUGH PLUMBING
work for which this permit is issued.
p 1 haw and will maintain worker)Compensation Insurance.ss mpui ed by Section 302 — TUB & OR SHOWER
3700 of the lacer Code,far the performance of dm work fm which this permit is issued. 303 — ROUGH MECHANICAL
My Work.e,Compevation Insurance tamer end Policy number are:
Cartier: Policy No.: 304 - ROUGH ELECTRICAL
CERTIFICATE OF EXEMPTION FROM WORKERS' 305 — FRAME
COMPENSATION INSURANCE 306 - HOLDOWNS
(This section teed not he completed if the Permit is for one hundred dollars(S100) 307 — INSULATION
m less.)
1 certify mat in the perf cam of the work ter hich Chi,Parent is issued,I shell Out 308 — SHE ETROCK
employ anyp�a.ipp4y mahncr�eo;;ubjpy to the worken'Compcnsnion 309 — EXTERIOR LATH
Laws rCali �7.LG(K� f
A ant / 310 - INTERIOR LATH
N CETDAPPtI If. ftcrng uCcnonsortficrom the
ode. mu old 311 - SCRATCH COAT
eine suhject to the Worker's Compensation previsions of the lahnr CMC.yw must
.JZ forthwith comply with such pmrisimuorCox Permit mull lac Carried rcvaked. 313 — ROOF NAIL
M
ECONSTRUCTION LENDING AGENCY 501 - FINAL ELECTRICAL ENERGY
'e = Ihereby affirm that themisAConswctionlending agency for the performance or
y' h1 dm work far which this pcmhiC is issued(Sec.3W7,Cie C.) 502 - FINAL PLUMBING ENERGY
00.. Q LiLcndcrnterk Aaamai sN.mc 503 - FINAL MECHANICAL ENERGY
L)0 504 - FINAL BUILDING ENERGY
1 agree met 1 have mea oris application eta sum that the abew information is
0 Wilding
1 agree to comply with all city and county ordinances veSOr and sou laws relating to 505 - FINAL ELECTRICAL
building conswction,and hereby euthetx rcprcaenutiws of this city to corer upon the V above-mentioned property for impaction purposes GAS EST
Fy (WO agree to saw,indemnify and keep harmless the City of Cupertino against 7 F I N
v) liabilides,judgments.costs and expenses which may in any way ammo egainiCseid City `T
U in consequence of the granting of this Permit. — f
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by5 0 CAL Date `
SOUR CERE¢¢U,LA'9O //
CAa�n fsN I l�3lDt Re-roofs 510 - NAL PLANNING
aumo
I'Apprcanvconeactor Dam INAL PUBLIC WORKS
�I HAZARDOUS MATERIALS DISCLOSURE Type Of RdcW`I
Will the applicant or future Wilding occupent store or handle hanNous material
as ac(ned by the Cupertino Municipal Code.Chapter 9.11,and arc Hcalth and Safety
We,Section 25531(.)? All roofs shall be inspected prior to any roofing material being installed.
'eyes ;pNu
Will the applicant or future building omupam use cysipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it henrdou,at,conumivnu as&road by the Bay Area Air Quality Managomcm all new materials for inspection.
Di trio?
' ❑Yes No '
I have read the hvstdous materials xquircmcr under Chapmr(r.95 ofare Calirm. y
Tia Health&SafnyCaadmu
c,Scc25505,25533 uW �
15534.1Mrsund thuifdm Wilding 2-3
dins rycoln Currently hese mvnl met it u my responsibility bin 'fy me cmupant
aqui nu, ¢h�ustp priormissuanceor.Camino,a cup.n Signature of Applicant Date
�s�etf(�u5fi/ 1, 'F L `�, All roof coverings to be Class "B"or better
0 ora armd agent Dam