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03100012 CITY OF CUPERTINOm�awrtx�e?>A .mx'" BUILDING DIVISION PERMIT CONTRACTOR INFORMATION ,s ,+asakir'. BUILDING ADDRESS: PERMIT NO.03100012 3100012 .1c) PURS RD / ERS NAME: PERMI717I5SIfEDATE C NE: SANITARY NO. CONTROL N0. ARCHITEC(ENGINEER; BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 o o LICENSED CONTRACTOR'S DECLARATION - ry i u af 1 hcreby firm hat I am licensed under provisions of Chapter 9(commencing IO Description with Secrce ndefec Division,of the Ousinesand Pro(essinm Cos,end my license is to LiruneCl and alma'' MODEL. ta? License Clan Lk.s i F� Da¢ Comncmr, DE ION I understand my pins shall sedas^LARArecords r' •� 5du app Licensed Professional 3 OWNER-BUILDER DECLARATION f 1 hereby affirm that I am exempt from the Contractor's License Law for the :COOfollowing..axon.(Section 703 1.5,Business and Professions Code:Any city or county which requirca a permit to convect.alter,improve,demolish.or repair any stmcmm onnno fly prior to its issuance.also requires the applicantfor such permit to file a signed statement < that he is licensed pursuant to the pmvisinmofthe Contractor's LimnmLaw(Chaptcr9 Sq. Ft. Floor Area Valuation . Z $ (commencing with Section 7").1 Division 3 of the Businammul Professions Code)or that be,is exempt dmrtfmm and the bnis for the alleged exemption.Any viol.fom of 35611006 . 00 Section 7031.5 by any applicant for.Panel,subjects the applicant o a civil penalty of APN Number Occupancy Type not mom than five hundred doll..($50(1). p y yP ❑I,ss owner of the property,or my employees with wages u their tale compensation, will do the woo,and the swcture is not Intended or offered for sale(Sec.7044,Business 101 — FOUNDe��Td IOSpeCt10DS and Professions Code:The Counoris License Law does not apply m an owner of property who bulls or improves toucan,and who does such work himself or through his 102 - PIERS own employees,provided that such improvements are not immndcd or offered for sale.If, 103 — UFER however,the building or improvement is sold within one>e r of completion,the owner- budder will have he Wrdcn of proving that be did not build or improve for purpose of 104 - REBAR aaea. 105 - ANCHOR BOLTS co 1.as owner of dee Sec.'Mo am exclusively contracting with limned cantracmrs to can.Lawct d pmjcn apply I.an ownBusiness arta property wh ions Wild.or I prove.he uactor',I.A. 106 — SEWER & WATER cense Lawaocanoupply loan with aofproperty whosepouant to becomes 202 - UNDERFLOOR PLUMBING ,Who contracts for such pmjeB with a conlnemr(s)licensed pursuant m the Contnetofa L ante,Law. 203 - UNDERFLOOR MECHANICAL lam exemp er Sec. Cuba Gar this ressan „� G� (,� 204 - UNDERFLOOR FRAME IMyr WORKERS COMPENSATION�E�ADTION�— 205 - UNDERFLOOR INSULATION I hereby aBinn under penalty of perjury one of the following declatnians 301 — ROUGH PLUMBING ne and will maintain a Cenificmc of Consent to selGWum fm Workee.Centric.. 302 — TUB & OR SHOWER - ,as provided for by Section 37110 of the labor Code,far he performance of he 303 - ROUGH MECHANICAL for which this permit is issued. ave and will maintain Wmeo's Compensation Insurance,m required by Section 304 - ROUGH ELECTRICAL of the Labor Code,for the performance of he work for which this pentyl is issued. � 305 — FRAME orker's Computations Insurance carrier and Policy number am: �'x tJrJ- 306 - HOEDOWNS Cartier. Policy Na.: CERTIFICATE OF E%EMMON FROM WORKERS' 307 — INSULATION COMPENSATION INSURANCE 308 - SHEETROCK or less)mis need not he completed lithe Permit is for one hundred dollars(31(rt1) 309 - EXTERIOR LATH 1 mnify,hat in he rmanee of he work for which Iota perch is issacd,I hall nut 310 INTERIOR LATH employ anypclmn r manner x as to become mbjecuathe wre"a Com par 311 — SCRATCH COAT lawaaf atimmia.D Appli 'I 313 - ROOF NAIL N TOAPPLICANT:If,aftermmingthisCcnificaaorE.amprn,yaudord, 501 - FINAL ELECTRICAL ENERGY become subject to the Worker's Compensation provisions of the Labor Code,you must �C forthwith comply with much provisions or his Permit shall be deemed Invoked. - 502 — FINAL PLUMBING ENERGY L� CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY I hereby al@m deal there is a eotatructinn lending agenry rot the perfurmnm of 504 - FINAL BUILDING ENERGY Y> theor which this permitisissued(S<c.3097,Civ.C.) da Q Lariat's Name 505 - FINAL ELECTRICAL ndcis Z)z L naetSAaa 4 506 - GAS TEST ;,)p 1 coolly hal 1 have read this application and mite that he above Information is 5 0 7 - FINAL PLUMBING D correct.I agree to Comply with all city and county tAfiW3ees and cute laws relating to (J Wilding cares 10 Co,and hereby auty and county his city t lewerupon the V ahovomentiuned pmpeny for inspection poroses. — FIWNWG,AL N a eWed.,me to cove,indemnify and kith harmless the City of C gamin against O 9 Fill' ~� IIab11111ea,Jadgmenb,Caa6 and expenses which may is any way BCCrve against mid City SIn consequence of he gronting wf this permit.PLICANT UNDERSTANDS AND WILL COMPLY WITH qLL NON-POINT Issued by: 5RKS Date OURC ULATI �/y � ° ��•2003 Re-roofs Signawre of ApplicnUCommalor 6m, HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will dee aripfcloo m future building occupant atom or hendlc humorous material as sfmcd by the Cupertino Municipal,Code,Chapter 9.12.and the Health end Safely I. Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. .❑Yes k1No Will he applicant or future building occupant use equipment dr device,which If a roof is installed without first obtaining an inspection,I agree to remove it havardous air contaminants u de0ncd by the Bay Arca Air Quality Management all new materials for inspection. istricl? ❑Yes Nu I have mad the haysrdousma¢rials requicmcnts under Chapterri.95 hills:Califon nia Health A Sxfe,yCnsa.Soetiota 25505,35533 and 25534.1 nsrnnM dew iflM building - doesnetcu III have a Rnnl.than its my hapreibilily In notify he occupnl of the myutm ta ichm Ihemat pdonaismnccofaCeNfa cy. 3Signature ofApplicant Date x✓0 a' Owner or euthori'reJ agent All roof coverings to be Class "B" or better ham t,