03090086 CI TY OF CUPERTINO +:a„3+<aw., at34e I mra'tx 'e;
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
0
u1LDING ADDRESS: IRVING STEPHEN M AND D L PERMIT N1b3090086
rod r-AQ1rT.WTLJN ST
R'S NAME: PERMITMUUE DATE
]NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT IN
BLDG ELECT PLUMBMECH
;oo LICENSED CoNfIFRACTDECLARATION Job Description
F I hereby.(firm that 1 am limed underderp provisions of Chapter 9(commencing P
K8 withllforcnnde)ecDiviaionJo(NC Business and Professions Code,andmyliccnxis MINA
Ee®
w in full force and effect. 'v hp`y
iq? Lieenm Clues Lie.M KITCHEN REMODEL/WINDOW UPGRA E
s Dato Contractor
stq• ARCHITECI-S DECLARATION p Q
f d 1 understand my plans shall W used as public records DEC O O 2003
y6
s Licensed Prorcainnel
7 OWNER-BUILDER DECLARATION BUILDING
2 n Y I hereby maso ,(firm on 1 am exempt from the Contractors License Lew for the
4 o O followingmason,a (Section 11131.5,Business and w.demolish.
Code:Any city s county
<m which requires a permit re quires the elle,improve,demolish, file
mash any tWdure
°z< pdonn its issuance.o.also eentto res theapplicantfor nthrator'soicense ned Law(Charter
-
Nntcislingw it Puravanuo Nc of Divionsnf the Contractor's Liccnseiaw(,CndO)Y Sq. Ft. Floor Area Valuation
2 (ted he
xempthherfromon and th Division)of the
eged rasaodon.Anyonsladon or
of
$ Net he Is exempt 1Mrtfrom end the bub for Ne alleged exemption.Any-violallon of 35620046 . 00
Section 9031.5 by any applicant for a permit subjects Ne applicant to a civil penally of ppN Number _ Occupancy Type
not more Nan five hundred dorm($5001. "' `-- P y -—
I,aownu of the ryopeny.or my employcu with wegu uNe'u sole compensation,
will do the work.and the swmure is not intended or offered for We(See.]044,Business lul - dInspections
and Professions Code:The Conmctor's Licca Law does not apply in an owner of 102 - P I ERS
pmreon
peny who builds or improve.The ,and who dm,..h work himself or through his
own employees,provided lost such Improvements arena,intended proffered(a,ole.It. 103 - UFER
however,the building or improvement is sold within one year of completion,the owner.
Wilder will have Nc twoh n of proving that be did not Wild or improve for porpoise of 104 - REBAR
ate')' 105 - ANCHOR BOLTS
❑Les owner of property,am exclusively contracting with licensed mnuaaon t.
construct the project
(sec.11kd,Business,and Prodwortcasians Code:)The Conutctor'e Li. 106 - SEWER & WATER
came taw does not appy in an owner of property who Wilda or improves homes,and, 202 - UNDERFLOOR PLUMBING
who contracts for such projects with a contnctor(p licensed Pursuant o Ne Contractor's
License Law. 203 - UNDERFLOOR MECHANICAL
Clem ex mpsunder Sec. ,B&PCfo-Itis pson 204 - UNDERFLOOR FRAME
°e1 ," `3 205 - UNDERFLOOR INSULATION
WORKERRSSr! MPENSATION��CLARAT
I hereby affirm under penally o(perjury Zr m2 awing declarations: 301 - ROUGH PLUMBING
I ham and will maintain a Certificate of Consent to self-insum for Wohars Compen- 302 - TUB & OR SHOWER ,
sasion,exprovide o Section 37W of the Labor Code.for des performance o(IW - 3 03 - ROUGH MECHANICAL
work for and ills perm tissued. 304 - ROUGH ELECTRICAL
El I have end will maintain Purfor Compensation Insurance, h inquired t i section
J100of the Labor Code,for dm pclfarmanccof the woo for which this permit it issued. � 3O5 - FRAME
My Worker's Compemnion lasunnce cannot and Policy number are: 306 - HOLDOWNS
Carrier. PIN No.:
307 - INSULATION
CERTIFICATE OF EXEMPTION FROM WORKERS' .
COMPENSATION INSU RANCE 308 - SHEETROCK
(This section Dead not W competed B the Permit is for one hundred dnum(SIm) 309 - EXTERIOR LATH
I lea.) 310 - INTERIOR LATH
employ cenify Nap In the performance of as work for which Ihis permit rk issued,l shall nm
ias California,person in any Goes manner sossm become subject loth Wohcts'Compensgtion 311 - SCRATCH COAT
Laws of COete
Applicant313 - ROOF NAIL
NOTICE TO APPLICANT:IL after making this Ccnificam of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become subject to the Worker's Compensation Provisions of the Labor Code,you must
�z forthwith comply with such provisions or this Permit shall be deemed ranked. 502 - FINAL PLUMBING ENERGY
�0 CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
I hereby affum Nat there is a e msructinn lending agency for the perrurmurim of 504 - FINAL BUILDING ENERGY
x > Nfor which Nla permit is issued(sec.3W7,Civ.C.)
Under'.
Meme 505 - FINAL ELECTRICAL
it Q Len der'.
jz LcndersAddress 506 - GAS TEST
:.l 0 I cenify that l have read this application and atom that the above infommalun i. 507 - FINAL PLUMBING
y f~ come).1 agree to comply with all city Bud county ordinances and sore laws relating to
�(J building construction,end hereby a I11047e tepresenutiveS of this city to enter upon Use FIN CCAL
U above-mentioned property for impaction purposes.
(We)agree to ave,indemnify and keep harmless the City of Cupertino against O 9 F I
ti fA liabilities,judgments,costs endeapenatwhich may in eraywsyecemeagainmsald City 5 NG
JZ in consequence of the granting of this r I. .�/�
APP I ANT UyyDERSTANDS A D ILL COMPLY WrIH-ALD?fON-POINT Issued by:5 &MEHAN
WORKS Date
sOlfl EGNLAT19NS.
Re-roofs
Signgpme o A IicanUCamran r
HAZARDOUS MATERI IS DISCLOSUR. Type of Roof
Will the applicant ser future building Occupant store or hardle hacardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and IM Health and Safety
1.qul
I-IYes zss3z(a)paAll roofs shall be inspected prior to any roofing material being installed.
❑roeWill the applicant or future Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
havmdom air contaminants u dcOned by the Bay Arca Air Quality Managcmem all new materials for inspection.
iel?
❑Yes ' flo1have read the hmardousmetorle8 requirements underChaper 6.95 of the Califor-
Wilding
n I cumamly have a tenant that h is my responsibility to nodly the pant of the
rats hkhmusWmelpdur ancmfaccmrlcamof SlgnatllfeOfApplicant Date
ner
ow , 1 it agent Da All roof coverings to be Class "B" or better