02100166 CITY OF CUPERTINo :4 - .- ��
BUILDING mvlsloN PERMITCONTRAC4rOR INFORMATION
BUILDING ADDRESS: LOVELACE CONST. PERMIT NO 02100166
OWNER'S NAME: 10144 CAMINO VISTA DR. PERMITMUEDATE
E: (408) 255-4923 SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLOC LECT PLUMB MECH
E
0 E 0 0
Too LICENSED CONTRACTOR'S DECLARATION
W 1 thereby affirm that l am licensed under provisions of Chapter 9(commencing Job Description
iYto with Senipn'lpkq al Divisi.nl.f the Buxi and Pmfessiom Cnde.and mylicens ix
'�„ mruum d reel. sj ADD 809 54. FT. G�6u�kt�'. y,
1 Z Liccnm Cl LIc.X
Date Cunt I
�ol �\ , ARCIIITECI'S DBC ATION SEP 2004
F
i s Y Lcrstais of glinsstallbeuuaa public rccmdx
>dU
"arLicensed Professional
• OWNER-BUILDER DECLARATION
Contractor's
ON BUILDING
1 n T I reason,
affirm on I ore exempt from me Cssions o :Any c Law for the IIwJ11 q6 IAI`FRI
O o followhich re reason.(fornit t ID3 L5,Business and sae,demolish.sio Cndc:Any city.,c.way
m 4 which d,issures n e.also re quires t e alter,improve, ritu or mpmg any structustatement
that
he ill Tensed p,aluantto the the
sofcant far Contrator'luiensele a Law(Cha mem
a (commencingwJpuntion7 theprovisionshe eBusinssandPrmlaW(Codr) 9 Sq. Ft. Floor Area Valuation
;F o teal he is exempt Section had the
Division r of me alleged
Business and Professions COlc)ser
a 3$ Nm he is exempt mc¢from had circ basil for me alleged caemption.Any violation of $100000
Section7B3L5 by any applicant for apvnnt subjects me applicant to a civil penally of APN Number Occupancy Type
not more man five hundred dollars(5500). P Y YP
❑ 1,ax owner of the property,or my employees with wages as their sale compensation. 34214082 . 00
will do the work,and the sa.cluro is not intended or offered for sale(See.704L Business
and Professions Code:The Comaccmr's License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who doessuch work himself or through his
own employ..provided malsuchimpmverecou see refinanced.,offered forsake.If, 101 — FOUNDATION
however.me building or improvement is sold within one year of completion,me owner
builder will have the burden of proving mat he did not build or improve for purpose of 102 - PIERS
salt.).
❑ 1,as owner of the progeny,am exclusively contracting with licensed c.naacmm to 103 - UFER
construct the project(Sec.70x4.Business;and Professions Codef The Conuaclor's Lt. 104 — REBAR
cerise taw does not apply to an owner or property who Wilds or improves demon,and 105 — ANCHOR BOLTS
who commas for such projects with a eontractods)licensed pursuant to me Conuanor's
Licen*eww. 106 - SEWER & WATER
0 1 am cacm pt under Sec ,B h P C for this mason
202 - UNDERFLOOR PLUMBING
Owner ate
WORKER'S COMPENSATION DECLARATION 203 - UNDERFLOOR MECHANICAL
I hereby aRmt under penny of perjury one of the following declarations: 204 — UNDERFLOOR FRAME
aeandwillmaintainaCenifiemeoreansentmself-insuremrWorkersCompen. 205 - UNDERFLOOR INSULATION
as provided for by Seen..37M of the later Code,far the perr.rmance of the 3 01 - ROUGH PLUMBING
wank for which this permit is issued.
l7 I Have and will maintain Workers Compensation Insurancesetret{uircd by Section 3 02 — TUB & OR SHOWER
nm of the labor Cade,for the Performance or be work for which this remit is issued. 303 - ROUGH MECHANICAL
My orkcrjCompeominnInsurancecarrierandPoll m r 0 304 - ROUGH ELECTRICAL
v/- rmz-� Pali°i zz
CERTIFICATE OF EXEMPTION FROM WORKERS' 305 — FRAME
COMPENSATION INSURANCE 306 - HOLDOWNS
tThissection need not Wcomplmcd irme permitisranonchunarcadollara(slit 307 — INSULATION
I cenay that in the perfamtance of the wart for which this permit is ismad,1 shall oat - 3 08 - SHEETROCK
employanyof .rain in any manner so u m become subject m the workers'Compensation 309 - EXTERIOR LATH
LawsApplicant 310 - INTERIOR LATH
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should 311 - SCRATCH COAT
became subject to the Worker a Compensation provisions of the Labor Code,you most
�Z forthwith comply with such prnvisMas Of this NoriL shin W deemed rovoked. 313 - ROOF NAIL
z� CONSTRUCTION LENDING AGENCY 501 - FINAL ELECTRICAL ENERGY
I heroby affirmmat mere is a conawninn lending agency ter the perrormuce of 502 - FINAL PLUMBING ENERGY
La the work for which this permit is issued(Sec.NAD,Co,C.)
i ^p Under',Name 503 - FINAL MECHANICAL ENERGY
Z <naerandam 504 - FINAL BUILDING ENERGY
J O 1 certify that 1 have read this application and std¢that the above information is
correct.I agree to comply with all city and county Ordinances and ation laws mating to 505 - FINAL ELECTRICAL
Vbuilding construct...and hereby turban.rcprouidovi s.1 this city in erne,.,on he GAS EST
shove-mentioned property for inspection purposes.
>r y (We)agree m save,indemnify and keep harmless the City of Cupertino against 0 7 F I
N liabifiaes,judgments.costs and expenicswhich may inany way aceronagainst said City 5 ICAL
JZ in consequence of the granting of this permit.
APPLICANT UNDERSTAND AND WILL COMPLY WITH ALL NON- OINT Issued by:5 Date
SOU REGUL TIONS.
�� 03 Re-roofs 557170 NAL PLANNING
isn,tu,e.rAppEe HAZARDOUS MATERIALS DISCLOSURE rififiacoor arc Type of Ro%o `I — FINAL PUBLIC WORKS
Will me applicant or future building Occupant store or handle hnrardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
cae.seeti.n2sslz(a)+ All roofs shall be inspected prior to an roofing material being❑rex P P Y g g installed.
Will me applicant or future building occupant sex equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
ozenous air,contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
crf
❑Yes
1 have mad the harantnus materials requirements under Chapter 6.95 of the Califor.
ma Hcalm&Safcty Colt,Salons 25515.25533 and 25514.1 tndcrsund that if he Wilding
does not currently bine a enant.that it is m raxponobb.1.tY m nod fy the omupxnl of the
rcyarce. nmssbe tpour,. anti ace,dfieamd eupaney. Signature of Applicant Date
Owner ser aummizeJ spuno All roof coverings to be Class "B" or better