03050002 CITY OF CUPERTINO � 4"' ' '" 1'-�' ` t" ""�•' ""� "' �
BUILDING DIVISION PERMIT CONTRCTORIN�ORMATON.-
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027 fro1eAROLINE DR PBRMIT"'.03050002
IWRP1YI REGBE PERMIT E ff jb1/2003
NE: SANITARY N0. / V CONTROL N0.
ARCHTIEC(ENGINEER: BUILDING PERMIT INFO
BO EO PLUMB
MECH
O
ri0o LICENSED CONTRACTOR'S DECLARATION JbDscri tion
I heNn
hereby affirm 1 ane moe
licensed under provisions of Chapter 9(co
mencing p
0 with Section 70(18)of Division 3 ofthe Burman ark ProfeW...Code,and my llcense ie
in full forceandeffect REVISION--IN HOUSE USE ONLY 4_110j 5 z License Clw uc.a
Dale Conuaemr NO NEW PERMIT, ORIG. #03020054
9 ARCHrrECPS DECLARATION
Iundenund my pbm that)lie mind as public recard, ELEVATION/GARAGE/DOORS OPENING
3 Licensed Professional
5
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt form the Contractor's License Law for the
0 0 following memun.(Section 7031.5,Business,and Profession Code:Any city of county
$ which requires a permit to construct tivi,improve,dcmoluh,or mpalr any strucmm
FZLa prim to its issuance.time requires ties applicant for much permit to Ole a signed anat•nment
<
that hei.Income Pursuant mmeprovisions ofthe Contractors U..U.(Chapmr9 Sq.Ft.Floor Area Valuation
€O (commencing with Section 7W)of Divism.3 of ties Bm.incssmd Professions Code)or
PRS that he isexeropt therefrom and the basis for the alleged eumption.My violation of
Section 7031.5 by my applicant for a permit subjects the applicant to a civil penalty of APN Number ,°CBe508rRy Type
not roam than five hundred dollars(5500).
0 1,as owner of the property,comy employee with wages u theirsole compensation,
will do the wart and the structure it not immmded cooBcred fronle(Sec.7044,Business
and Proftemons Cade:The Cormamer's License Law don Ives apply m an owner of Required Inspections
property who builds ofimprowt theman,aM doatuch work himselfarWough his
ownemploym,provided that such Improvements ere not intended oroBered forWe.If. 101 — FOUNDATION
however,the building or improvement is sold within oro you ofcompletion.the owmrcr.
bulldu will have turden o
he bf pmving the he did rot build or improve for purpose of 102 — PIERS
sale')' 103 — UFER
0 1,as owner of the property em exclusively contracting with licensed conmsnms to
consumer the pmjeci(Sec.70"4 Business and Profession,Cade:)The Contractor's LI. 104 — REBAR
caw law does not apply m an owns of property who wilds or improv thereon,and 105 — ANCHOR BOLTS
who contents for much projects with t eoauaetortU licensed pursuant m the ConuaetoM1
Lic—Lan 106 — SEWER & WATER
O'me.maptundersee. .BkPCfmthmreaaon 202 — UNDERFLOOR PLUMBING
Date 203 — UNDERFLOOR MECHANICAL
WORKERS COMPENSTMON' DECLARATION
I hereby since under penalty of perjury one of the following declarations: 204 — UNDERFLOOR FRAME
O l haw and will maintain aCeNRcam occouscut to sel6iuure fmwarkcr's Coupon. 205 — UNDERFLOOR INSULATION
satlan,M provided for by Section 7700 of the labor Code,for the performance of the 301 — ROUGH PLUMBING
work for which this permit it Issued. 302 — TUB & OR SHOWER
0 I Mw and will maintain Workers Compewdon Inhumane,as required by Section
37MofOuraborCode.for thee petfmmwteeofChe work rear which this permit ialww. 303 — ROUGH MECHANICAL
My Worker',compewdan mamam arria ave Policy number are: 304 — ROUGH ELECTRICAL
Carrier. PolicyNo.: 305 — FRAME
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 306 — HOLDOWNS
(This mucron need not m oomplemd ifine peemh lit fmone hundred dollars glm) 307 — INSULATION
lemu') 308 — SHEETROCK
I cenify that in the performance of the work for which this Permit is issued.I stall not 309 — EXTERIOR LATH
employ any Person in any manner an u to become subject to the Workers'Conporm loo
Laws ofCalifornia Date 310 — INTERIOR LATH
Applicwn
NOTICE TO APPLICANT:IL after making this Certificate of Etcmption,you should 311 — SCRATCH COAT
become subject to the Woher's Compensation provisions of the Labor Code.you must
�Z forthwith Comply with such porohl.nsmthis Permit halt wdeemed revolted. 313 — ROOF NAIL
zy CONSTRUCTION LENDING AGENCY 501 — FINAL ELECTRICAL ENE
thereby sin.that d .I.acoruuucunnlending sgenryrat the Performance of 502 — FINAL PLUMBING ENE
x > the work fmwhi,boil Permit I.issued(Sm.3097.Civ.ca 503 — FINAL MECHANICAL E R
Lender's Name
W
PZ (`ndcriAdOia' 504 — FINAL BUILDING EN G
U O 1 coolly that 1 have read this application and some that the chew information L 5 05 — FINAL ELECTRICAL
IT, correct.I gree to comply with all city and county ordinances and sum law mining to
O buildigconsvection.andherebyauthorizempmxnulivetofthiscitymenuruponft GAS EST
W aM1ow"me e)a mil gree in any for indemnify
an keep ha /
y (We)agree ro taw,or lnsr ify ac d keep humleu he City of Cupertino against 0 7 FIN
Iq liabilities,judgments,costs and expenses which may In any soy scene against said City 5 A ICI
g� /
U Z In consequence of the graining of this Permit. LV\
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:5 Date
SOURCE REGULATIONS. _
Signature o(AppliantContractor Dao Re-roofs 574 INAL PUBLIC WORKS
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant sorra or handle hundous mamdal
as&R"ed by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Section 35533(.)7 All roofs shall be inspected prior to any roofing material being installed.
[3 Yes 0N
Will the appfiam or future wilding Occupant w equipment or mV1ecs which If a roof is installed without first obtaining an inspection,I agree to remove
mit havaednm air cmmmmiw t a defined by the Bay Are,Air orality Management. all new materials for inspection.
District?
0Yet (:I No
1 haw mad the hwrdrms meterialamquimmenu undcrChapmr6.95 of the Califory
ni.H.Il 'Saf.iy Codd,scetimu35505.25533.d25534.1.ndcrsmnd thuifdtc wilding
duet nor currently have a amount.that it u my respomlhlllty m n"dfy the occupant of site
mqulrements which must W mer Prior to issuance of a Certificate of Occupancy. Signature Of Applicant Date
Owner or authorized agent Dam All roof coverings to be Class"B"or better