03020036 CITY OF CUPERI'INO - -s
BUILDING Dlvlslory PERMIT `CONTRACTURIINFORMATION '•b%
BUILDING ADDRESS: HANIWAY COMP. PERMIT NO,
22116 CLEARCREEK CT 0'40200-46
NER'S NAME: 150 W. IOWA AVE APPLICATION SUR DATE
JEORGE & JOANNE HSING 02/11/2003
ONE: (408) 733-3755 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
p^00 LICENSED CONTRACTOR'S DECLARATION Job Description
u� 1 hereby af0rm Bad I am o
licensed under previsions of Chapter 9(commencing P
with Section Mk)of Division 3 of the Business and Pnsfessions Code,and my license is
iri fall force ad effect. REVISION--IN HOUSE USE ONLY
C O t2 S License Class Lic.11
?yFo Date—TSDECL
mr NO NEW PERMIT ISSUED, ORIG.
OATION
ut
I undersand my plans shall u d. public nW, (CUSTOMER LOST JOBB PLAN) o uv
cO
�3 u Licensed Pnrfessional
OatN[m BUILDER DECLARATION
ty+ 1 booby.affirm Not I ore ucmne from the Contractor's C's License Law lou the
t—�O
i p 0 fallowing reason.(Soden 11Gstr Business and Professions Gide:Any city s county
an$ which requires u Pmmit w construct,alter,impmvc,demolish,or repair any structure
an an prior to its issuance.&lass requires she applicant for such Permit o rile a signed statement
rgm< OurWislicensedpursuammtheprovisionsoftheContractor'sLiccmelaw(Chapter9 Sq. Ft. Floor Area ni Valuation
aFa (commend ng wi th Section 7000)of Division 3 of the Business and Professions Code)or
$ that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 1011.5 by any applicant for a Permit subjects the applicant no a civil penalty of APN Number yType
not more the Five hundred della.($500).
32618 022 . 00
�I,uowner of the property,or my employee with wage estheir tale comPensasion.
will do Ne woh,rid the asrucwre is not intended proffered for sale(Sec.]044,eusinea
and Profesesioru Code:The Commences License Law does bill apply m an Owner or Required Inspections
pOpeny who builds or improves thereon,and who doessoch work himaelfor through his
ownemplayeu,provided that such improvements tie not intended or offered for sale.If, '101 — FOUNDATION
however,the building or improvement is sold within one year of completion,the owner.
builder will hail the burden of proving that he did not build or improve for purpose of 102 — PIERS
sic) 103 - UFER
C]1.as owner of the propeny,am exclusively contracting with licensed contractors to 104 - REBAR
consumer the project(See 7044.Business and Professions Code:)The Contractor's Li.
cense law does not apply to an owner of propeny who builds or improves demon.and 105 — ANCHOR BOLTS
who contracts for such pmjects with a efrometor(s)licensed pursuantto the Contractor's
License law. 106 — SEWER & WATER
l am exempt under Sec. .B&P C for this reason 202 - UNDERFLOOR PLUMBING
mer Date, 203 - UNDERFLOOR MECHANICAL
WORKER'S COMPENSATION DECLARATION 204 - UNDERFLOOR FRAME
thereby alrum under penalty of perjury one of she following declamations:
205 — UNDERFLOOR INSULATION
❑Ihnvc and will meintainaCenifkak ofCmxnl toself-insureforWuher'aCompen-
sation,a provided for by Section 37W of Ne Labor Code,for the performance of she 3 01 - ROUGH PLUMBING
work for which this permit is issued. 302 — TUB & OR SHOWER
❑ 1 have and will maintain Worker's Compensation IMumbec,as required by Section 303 - ROUGH MECHANICAL
3WI0 of Ne Labor Code.for the performance of Ne work for which this permit is issued.
My Worker's Compensation Insurance carrier said Policy number am: 304 — ROUGH ELECTRICAL
Cartier. Policy No.: 305 - FRAME
CERTIFICATE MPENSATIONIINSURANCON MOM EGRKERS' 306 - HOLDOWNS
(TTissection food not he completed ifthe Permit is formic hundred dollars 307 - INSULATION
orless.) 308 - SHEETROCK
1 certify that in the performance of the work for which this Permit is issued,I shall not 309 - EXTERIOR LATH
employ any peva m in any manner sm re to become subject to she Workert Compensation
Laws of California.Date 310 - INTERIOR LATH
Applicant
NOTICE TO APPLICANT:If,alter making this Certificate of Exemption.you ahold 311 - SCRATCH COAT
become subject to me Worker's Compensation previsions of the Labor Code,you must
Q z forthwith comply with such previsions or this Perm itshall 4 deemed mvokd. 313 — ROOF NAIL
?o
CONSTRUCTION LENDING AGENCY 501 - FINAL ELECTRICAL ENERGY
[.. .Nr I hereby effort Out there is a construction fending agency of the perlivmenccol 502 - FINAL PLUMBING ENERGY
WoOn nder's k Nawhich this permit is issued lSec.3151,Civ.CJ
WQ 503 - FINAL MECHANICAL ENER
W wmc
2 z Lender's Address 504 - FINAL BUILDING ENERGY
U O 1 cenify that I bac read this application and sok that the above information is 505 - FINAL ELECTRICAL
Lt. F correct.I agree to comply with all city and county ordinances and state laws refining to
O U buildingconswction.andherebyautharimrepresentativesofthiscitytocrimeuponthe GAS TEST
W above-meminned property far inspection Purposes. O7 FIN
lCy' (We)agree no save,indemnify and keep harmless the City of Cupertino against
W liabildies,judgmen.,costs and expenses which may in any way accrue against said City Cj A C ICAL
U z in consequence of the granting of this permit.
.. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:5 Date
SOURCE REGULATIONS. _
Re-roofs 514 INAL PUBLIC WORKS
Signature of ApplicntlComre DDateHAZARDOO US MATERIALS DISCLOSURE Type of Roof
Will the applicant
rmfurore building oenpntsoneor handle Health and
.ss defined r she Cupeninu Municipal Code,Chapter 9.12,and the Hcahh and Safety
aside.Satin 25532(x)1 All roofs shall be inspected prior to an roofing material bei. Installed.
❑tea ❑Nm P P Y S g
Will 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
emit his rdous air contaminants as derined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes C]No
1 have read the haaardous materials requirements under Chapter 6.95 of be Califer-
niaHealth&Safely Code,Sccdnns 25915,25533 rid 25534,1 understand that if the building
does not currently have a knan,Out it is my res,onsihility to.sdfy the Occupant of the
requirements which mmu to met prim to issuance of a Cniricate of occupancy. Signature of Applicant Date
Owner mithurredagent Date All roof coverings to be Class"B" or better