00050183 CITY OF CUPERTINO - lDgsoo
BUILDING DIVISION PERMIT CONTRACTOR INFORhgnON:'
BUILDING ApDyIy�1 CARVER DRIVE nn ^n PERMIT NO.
OWNER'S N PF RRY MM/A�tDDOX /, ULJ A PPLICATION SUB DATE
PHONE: SANITARY NO. C L
G de z ARCHITECtAINGINEER: BUILDING PERMIT INFO
Q O O - BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
z z y z 1 heron nflinn that 1.m licensed under aeon ter v(e.mmme;n Job Description
p N_ Y provisions o p g
G �w with Section 71XX0 of Division 3 of the Business and Professions Cde,and nay license
SS, Ix in full force and effect.
1A,
z C a Liters.Chas Lic.g
3 N Dam Conmacmr .
F l O S ARCHITECT'S DECLARATION_
!!ff 1 understood my plans shall be used as public records
LicensedPropotti^nal ADDITION TO FIRST AND 2ND STORY
OWNER-BUILDER DECLARATION
t3 1 hereby M.aha 1 vat exempt from the Contractor's License Law for the
C < following reamn.(Section 703 I.S.Business and Professions Code:Any city or county
I%❑ which requires a permit to construct,alter,improve,demolish,or reply any another
t�3se
Her to its ins...an,Am requires the p,l,..,for such peamitto file aligned statement
.but M is licensed puaaumt to the provisions of the Contracmis License Law(Chaper9 Sq. Ft. Floor Area Valuatio
(commenting with Section 7")of Division 3 of the Business and Pmfcipwris Code) '�100860
or that he is exempt themfrnm and the Buis for the allegal exemption.Any violation
of Section 7031.5 by my applicant for a permit subjects the applicant o a civil penalty �r
oo�af�not mom than the hundred dollars($500). A 37532004. 00 Occupancy Type
Nil.us owner of the Fronted,.,my employees with wages as their sole compensation,
will do the work,and the vin coure is not intended or oRered for sale(Sec.700].
Business and Professions Cade:The Contrmmr's License law dices not apply m an Required Inspections
caner of property Who holds or improves thereon,and who does such work himself
.r through his own employees.provided that such impnwe ends are not intended or
offered far mn.IL m
however,the building or improveent is sold within one year of
completion,the ownerfhuilder will have the burden ofproving that he did not fodder 101. — FOUNDATION
imp... purposes
❑L ux owner ut'tlm properly,um exclusively containing with licensed contractors to 1.02 — PIERS
combun the project ser.7044.Business nod Professions Codep) the Carlon m'x 1.03 — UFE R
License Law Anes not apply to an owner of property who builds or improves thereon.
and who contracts for such projects with it eommemr(s)licensed punnnot to the 1.Q14 — REBAR
Contractor's License Law.
❑lame pIunderSee B&PCforthisrcaarm 105 — ANCHOR BOLTS
owner��rt� Date S� Z � 106 — SEWER tF WATER
N S C aMPCNSATIO DECL RATION
I lack, !no aomrpe.onryofp pry^m^na,alliwingd loniona: 202 — UNDERFLOOR PLUMBING
1 have and will maintain a Certificate of Consent to self-insure for Worker's 203 — UNDERFLOOR MECHANICAL
�x
J Compensation, ax provided for by Section 37M of the Labor Code, for the 204 — UNDERFLOOR FRAME
mit
prommus rce of the work for which this peris issued.
❑I have vad will maintain Worker's Compensation lnsumnce,as required by Sandal 205 — UNDERFLOOR INSULATION
37W of the Labor Code,for ma performance of the work for which this permit's 301 — ROUGH PLUMBING
issued.My Workers Compensation Insurance carrier and Policy number art:
Carrier Policy No.: 302 — TUB & OR SHOWER
CERTIFICATION OPEXEMPTION FROM WORKERS' 303 — ROUGH MECHANICAL_
COMPENSATION INSURANCE
304 — ROUGH ELECTRICAL
(This xcminn neeA on he completed if the permit is for one hundred dollars
(s I1Xn.r Deana 305 — FRAME
1 atoll thin in the performance of the work for which this permit Is issued,1 306 — HOLDOWNS
shall nal employ any Iprson in any romper as as to became subject to the Workers' 307 — INSULATION
Comparison ion lawn of California.Date
Applicant
NOTICE TO AI'1'LICANT.II.after making this Certificate of Exemption,you should 308 — SHEETROCK
Qbecome subject n the Worker's Compensation pro inions of the labor Code,you must 309 — EXTERIOR LATH
forthwith comply with such provisions or this permit shall be deemed raccoon.
4 CONSq'RUCf1ONLENDING AGENCY 310 — INTERIOR LATH
I hereby.Men,that them;,.c......tion leadingrade for the performance
of,beworkfowbichmispeorad sruedlSec.3097. i¢Oly pe 31.1 — SCRATCH COAT
y p Lender's Nnmc 313 — ROOF NAIL
� Z L<nder'a is
U O Icenifythat Ihave readthisvpplicmionendsmmthatthe.b.veinfpmatimis 501 — FINAL ELECTRICAL ENERGY
coined.1 agree m comply with all city and county ordinances and slate laws minting 502 — FINAL PI_LIMB I NG ENERGY
C.) to building connotation,and hereby solitaire representatives of this city nt enter clam
r w .he.Ipve.mmtomd mR"yf^"nalK°ion opposes' 503 — FINAL MECHANICAL ENERGY
(We)agree to save,indemnify and keep harmless the City of Contend..against
to Iiabilitin,jvdgmcros,casts onJ penal which may in anyway eccme.gmnst said 504 F 1RL BUILDING ENERG
City in cnnxequaaca of the gram gof this permit. ¢Q ^^'��
AP TUNDERSTAND DW 1 COMPLYWITHALLN P01 �-p�� rV
SOU CI' 1ECULATIONg, JV/��,rtL,f4I'„ ' ,� Issued by: 50� INAy EI_ECTRICALDate S
TEST
Sign u o pit WC AZARDn^S`_ I Dam Re-roofs a — w
Hn7.ARDOe 'ERIAI.S am'a
baDISCLOSURE 507 — FINAL PLUMBING
Willthcap c:mnnrllnurclntilrmgnccupamamreorhmWlebnennlnus'.meet eofRoof
n.v
do red by the panlnn Municipal Code.Chapter 9.12,and'he Hmllt and Sanity TYp 508 — FINAL MECHANICAL
Code Section 255 32(01
ores 3A4n All roofs shall @iAs fMctFdlIWMf-toQAf gWfing material being installed.
ti tWill the applicant or furore building occupant use equipment or devices which If a roof isinsraftAwithFUNALobffirAWNi1tllpeetion, Iagree toremove
emit hmandoox uia mmamimnts us defieayrcar Qua
d by the BAAil Mainlander,
Disarm'? all new materi513for iBs1Vc1NMLAft1J h Wd4MIk%9nd will comply with
°Yes 741ohn all n int source r ulations.
1 have reed he eOmNous materials coq,25533 a undo Chapter 6,95 of the
Calif.1 h Health d he bec Chile,Scott roarr a 25505,2 menu J dery C 1 undersand that
the
ifthe building dtrsnotca tall have. mem.ho dannyma,mrsihifnymtmtfythe Q
u ybtLms,repair m vl ich mus,W met prior m issuance 14 f a Cenifcam^f
(kcu ancy. �I/�
Sign t re of plicant Date
ow. lunho a .gem Deal All roof coverings to be Class "B” or better
OFFICE
Alp-
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