03010111 CITY OF CUPERTINO a" 7 -•
BUILDING DIVISION PERMIT CONTRACT
`✓�_ OR INFORMATION:W
x:
BUILDING ADDRESS: OLYMPIC RESTORATION PERMIT NO.
10313 COLBY AV 01010111
WNER'S NAME: 140 ARCHER ST. APPLICATION SUB DATE
TUTTELMAN IRWIN AND VERNA TRJS 01/22/2003
"ONE: (408) 437-2750 SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECI
0 0 0 0
p00 Lm chat I LICENSEDCONTRACTOR'S
under
DECLARATION Job Description
Ii G 1 ion 7( affirm chat 1 am licensed under Provisions of shaper 9(commencing p
with Section)tyn)of Division3of Ne Bnsineas and Pnsfessiom Csde,and my license is
G� Nmummyyn ren. I �)'m 170 -- HOUSE USE ONLY
y�z LlcenSC
o?- o Cnntr ter vTI < c NO NEW PERMIT ISSUED 02120061
-—/I understand my Plans sM1all he used a lie recnrtlx
n OiaO
U.0 Licensed Professional
OWNER-BUILDER DECLARATION \
tar<� 1 hereby Maso .l Stem that I am exempt e from the Contractor's o :License Low lin the
le p O following beawn.(Scaion 7(171.3,Business and Professions Code:Any city or county g�
°' $�i which requires a Permit to construct,alter,improve,demolish,or repair any soucmm V
1—Zx prior an its issuartm,also requires the applicant for
such Permit
file.signed statement
mm< that he islimmardpursuant inthe pmvisionsoftire Contractors License LawChapter 9 Sq. Ft. Floor AreaValuation
F$ (commencing with Section 7")of Division of the B usiness and Professions Cde)Or 60000
r,3.. Nat he Is exempt therefrom and Use l a i.for the alleged exemption.Any violation of
Smoot 7031.3 by any application far a Permit subjects the applicant to a civil penally of APN Number Occupancy Type
not more than five hundred dollars(5500). 31629026 . 00 p y YP
❑I,as owner of the property,or my employees with wages a Nair sole compensation,
will do the work,and Ne aaucmm is not intended or.ffn.d for..In(Sec.70144,Business
and Professions Cale:The Convector's License Law does not apply in an Owner of 101 - FOUNDArglt�fed Inspections
property who builds or improves Ibereon,and who docs such work himself or through his
own employees.Provided dtatsuch improvements am not intended or onered for sale.If. 102 — PIERS
however,the building or improvement is mid within one year of completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of 103 - UFER
m'e) 104 - REBAR
❑I.as ownerof the pmpcny,am excliaivdy contracting with licensed cmdracmnm 105 - ANCHOR BOLTS
convect the pmjeut(Sec.704x,Business and Professions Code)The Contsacmrs Li-
cerise Law does not apply to an Owner of property who Wilds or improves themon,and 106 — SEWER & WATER
who contracts for such projects with a commctor(s)licensed pursuant in the Contractor'. 202 - UNDERFLOOR PLUMBING
License Law.
❑l am exempt under Sec. .B&P C for Nis reason 203 - UNDERFLOOR MECHANICAL
nor Data 204 - UNDERFLOOR FRAME
WORKER'S COMPENSATIONDECLARATION 205 - UNDERFLOOR INSULATION
I hereby affirm under penally of Perjety one of the following declarations: 301 — ROUGH PLUMBING
❑1h.v<and winm.iby Stc.O 37eofoo, ent to Labrutel6inmm for Woorneraomper.f,he 302 — TUB & OR SHOWER
ration,m provided for by Section 37W of Ne labor Code.for Va peRormame of the
work for which this peonit is ismed. 303 - ROUGH MECHANICAL
P�rhava and will maintain Worker's Compensation Insurance.Us required by Section 304 - ROUGH ELECTRICAL
7700 Of Ne Labor Cale,for the performance Of Ne work for which this permit is issued.
My Worker's Compensation lnsurmtce carrier and Policy number art: 3O5 — FRAME
carrier: SYzafV Tt ..a +.� Policy No-: 00W 9 3 06 - HOLDOWNS
CERTIFICATECOM PENEXEMSAT ON3ON INSUR CERKERS' 307 — INSULATION
('ITis section need not M completed if dm permit is for one hundred doll=($IM) 308 - SHEETROCK
mless.) 309 - EXTERIOR LATH
I worry that in the perfmmance of the work for which this Permit is issued,1 shall net 310 - INTERIOR LATH
employ any Person in any manner sm as to become subjectto the Workers'Compensation
Laws of California.Dam 311 - SCRATCH COAT
Applicant
NOTICE TOAPPLICANT.IL after making this Certificate of Exemption,you should 313 - ROOF NAIL
become subject to the Worker's Compcnsation provisions of the Luton Code,you muss 501 - FINAL ELECTRICAL ENERGY
OO forthwith comply with such provisions or this Permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
N Ithereby aOrmNmthem isaconstruction lending agency[or the performmce^f 503 - FINAL MECHANICAL ENERGY
do
o
do,work Nac or which this Permit is issued(Sec.7fnT,Civ,CJ
w 504 - FINAL BUILDING ENERGY
fy Q ,work
07 Z LcnderaAddmmss 505 - FINAL ELECTRICAL
U p 1 certify that l have mad this application and sum that me mum information is 506 - GAS TEST
IL F correct.I agree to comply with all city and county ordinances and stale laws berating to
0 U building construction,and hereby authOHXreprescntativesofthis city to enter upon thc 5 FINAL PLUMBING
above-mentioned properly for inspection purposes. 08 FIN L
(We)agree to sate.indemnify and keep harmless Ne City of Cupertino against
V V) liabilities,judgments.costs and expenses which may in my way see=against mid City 5 N
in consequence of the granting of this Permit,
APPLICAyT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by51 - NG Date
SOE L TP S.�
Icy Re-roofs
UR (
Sign of ApplicanUContsecmr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant inflame building occupant stem or handle havardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
car,Section 2553200? All roofs shall be inspected prior to any roofing material being installed.
❑Yes on
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hannh us air contamiwnts as fined by the Bay Arca Air Quality Management all new materials for inspection.
Dia nT
❑Yes
I have read the haaaNnus mamrialsmquimmenL.under Chapterb.95of the Califor-
nice Health&Safmy Csdc,Scniuns 25505,25533and 25574.1 undersand datifthc Wilding
does not currently have a tenant,Nat it is my reslmosibility to nary the Occupant of the
m hw 'chmu be I 'Ormissualowe. .Ccnificatco ruPanL�j Signature of Applicant Date
Owner or outhOriMd agent ILV Dec All roof coverings to be Class"B" or better