02050177 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
"TMnDnRNE AVE PERMIT NO. 02050177
•T""NELEN AUY172CI72 M
1 PHONE: SANITARY NO. CONTROL NO,
eco zo ARCHITECTMNGINEER: BUILDING PERMIT INFO
w C BLDG ELECT PLUMB MECH
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m= LICENSED CONTRACTOR'S DECLARATION Ir,fa t��,Crip(�gy3,
jz in Ihereby affnd that l am licensed under provisions of Chapter 9(commencing CONVERT FAMILY 1.� 02t5 l5 `, ICE
=h wiNSeci n 7")of Division 3 ofill Business and Professions Code,and my license
m5 is in tut orce end edec `
ca so Lice las Lick Gob OJO
i3 u one Contractor
p ARCHITECTS DECLARATION
0 3 1 underhand my plans shall he used as public recordsPEL
i n
1 25 p O Licensed Professional •'� 'ii '""
OWNER-BUILDER DECLARATION \,.
y 1 hereby e0iim thin 1 am exempt from the Contractor's Licens the
r
Code: L_ $35000
t < followingrcasoa(Section7metra Business end Professions Any yorcounty /
F C
which req n perrmt m c n wet eller.Improve,demolish,or upai sty swcwu ��
3$ priort taissuance,also requires the applicant for such peram i Glean semen - _____
- Valuation
that fa i licensed puixom t the p r ns of Ne Contract. L cense r
(comma a ng with Sect o ]0011) f D inion 3 of the Business aM Pro(essI as a
or Choi he Is exempi therefmmand th<bazis far the alleged uemption.Any violation - --OfSection 7031.5 by any appliam fief o permit subjects the opplicont to a civil penvltyp y •J p
:otnot morethan rive handled ch.11.(S500). APN .. : Occupancy e
)OL asownerofthe propsny,or mycmployces with wages as their sale compensation, 102 - PIERS
will do thework,and the structure is not intended orarcered'for sale sec,7oaa, -- u r mmRequired Inspections"
-f usiness'amnorm nd Professions Code:The Cont 'a License law does not apply an '
owner of property Who Wilds or improves themon,and who does such work himself 104 - REBAR
or ere gh his
i own
employee..provided that h improvements art not intended or 1 5 -- -ANCHOR-'BOLTS" - `--- - - - -- - -- -BOLTS-
.offered sale If,'h e' thebuilding - improvement is sold within one year of - - —'
,
casaoe p r-Wilder whhave meWmenarprovmgmntnedid naaiiaar 106 - SEWER & WATER
improve for purpose of cele.).
_ _.. ._. _ - -UNDERFLOOR PLUMBING.- _-
O l a *owner ejec property am exdusry ly t Ing N I¢cnsW toms reactcousin,
aonswcttheproject Isec.70aan..at o andProfessionswho cure3The
ve.thaera 203 - UNDERFLOOR MECHANICAL,.,:-
License
-• Law does not apply a an..at wi e property rmi , lice sed pursuant
thereon, 204 _- UNDERFLOOR_FRAME
..and who cud rons-forInch projects u comncmr(s).licenud purmant toshe.
camneroYTuenu Law" .. 205 - UNDERFLOOR.•. INSULATION
t ❑lam m s / BSPcmrmisrt.on 301 - ROUGH PLUMBINd
D ER'SCOAIPDFU`mAT10PD 302 - TUB & OR SHOWER
Ihereby affirm under penaPyof Perjury one ofthetollowingdeclarnlons: 303 - ROUGH MECHANICAL
0 1 have and will:mountain i Canifiom of Consent to self-iname for worker's 3 04 _ ROUGH ELECTRICAL
Compensation, as provided for by Section 3700 of the Labor Code, ler the 305 FRAME
-_ performance of work ler which this emit is issued. 306 - HOEDOWNS
0 l have ane will maintain Worku'e Cona,manion lnsunnce,ai rt,noul by Section 307 - INSULATION
performance of the work for which this permit is
Compensation Insurance tamer and Policy number are:
`
of he
308.._-- SHEETROCK.._. _ - ---
iss�J MY Workers od�alarstheo•. ... .. ..__ . .... .. - _-_ ..
�cetner ,r- 'ri. i'� '„(..,.a Policy N.,.. ;309'"'-OEXT,ERIOR.,LATH- .
I .,CERTIFICATION OF EXEMPTION FROM WORKERP' -- f. r, t�.. . . ,n. k;
COMPENSATION INSURANCE '• __,310_..--_..INTERISIR_-LATH—
r-, 1
COMPENSATION .,.... .._ .._ __ . ._.__- __
' '(This sen on need not W completed if the Permit is for one hundred dollen 311 - SCRATCH COAT
1$100)°ncss) . 313 - ROOF NAIL
I candy likad in. perrowoce o
nf, k
for which this pe t sissued.1 - -501 - FINAL ELE CTRICAL�',ENE RGY
shall not pl y any per rson m a new m become aub3ect to the Work,.'comp ton Laws of Colfomia' 502 - FINAL PLUMBING ENERGY
:rAimic` ArPLICAN ..'If.after makmgtm:cartiee;teion.you should - _ 503' - FINAL MECHANICAL--ENERGY - -"'- -
become cito the Worker's Compensation provisionsoftheLenorCade,You mast 504 - FINAL BUILDING ENERGY
O 0 forthwith comply with such provisions or this permit shall be deemed revoked.
ZR _ . .. _. .- _. .. . . 505 - FINAL ELECTRICAL --
rCONSTRUCfIONLENDINGAGENCY A
_.
" 1 hcrcby affirm that the aooh et mg dagency f, th performance 506 - GAS TEST '
W Le work for is a Na"!!_Tit( aneatse.3097Civ.c) 507 --FINAL -PLUMBING--
'Address,
F Lend I certifyNat I heavy rod this a y application and state t adirr'.Name -,� -
UC .. r 508 - FINAL MECHANICAL
06 pp that abs informationis509 - FINAL GRADE
eorrtct I rete a mm d he all rot and countordinances dna acme laws elating
O V th abo gcmlioneion enihe byspecti n posenmaivesofahscryt enter upon 510 - FINAL PLANNING
-W the abs e m maned property for inspection purposes
.a (W) gmeto ts.con dempenseskeep ihemleinmy otCupekino 514 - FINAL PUBLIC WORKS
Q!) Citb in ca judgments. oats and expenses th which may in any ay accrue egeirist Diel
W. City n co sequence of the gn s(this gemma
APPLICANTU } WILL COMPLY w'mi ALL WN POINT° r
- s REG Issued by: Date
Signa u e of pp c o towtur .: Dae Re-roofs
”HAZARDOUS MATERIALS DISCLOSURE -" "'
Will the 4pl ant m future Wilding oat pant same or handle hexardmrs mated Type of Roof
udefined by the Collection Municipal Cod Chapter 9.12,ens the HaIN and Safety
t -
CdJSSccYcosn25532(ett /A
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O .d _. . a,. ( r• • 1 ' +e�
MfXO All roofs shall be inspected poor w,any roofing,material being installed,
Wilt the pplsv t r rtIn ung occ p muse wmom t or devices'which If a roof is insialled without fust obtaining an inspection,I agree to remove
tIcEfirelard.
m t l x d s au cont m t c mW by the Bay Arca A r Quality Management
Otsubo? all new materials for inspection_ Applicant understands and will comply with
Duca ,, ' - all non-point source regulations. -
� I he�e read ihe.haLe'Nouslmaterials nmulrementa Ender Chaperrr.95 of the `He510,&Safety Code;Sectlom 25505,25533 and 75530.1 undenund that
if Ne Wilding does concurrently have aterom,that it is my responsibility t°notify theoccupant of the requirement,wht Dat pr be m,t onto issue o a Ceniricate of
°rvpo �� Signature of Applicant Date roof cover
��(55 All f in s to be Class"B"of better
NlSaAa nth° edgen
'ul C oro g
-- - OFFICE
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