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03070098 CITY OF CUPERTINOta � s �rnrt' BUILDING DIVISION PERMIT AGO &T, NFQRMATION af34,' .::Fk. BUIL DING ADDRESS: PERMITN003070098 OWN114 CoNrIPR214 ER'S NAME: PERMIT ISSUE DATE NE: SANITARY NO. CONTROL NO. AR CHITECfIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH a�oo LICENSED CONTRACTOR'S DECLARATION I herohy affirm that I am IhenuA under provisions of Chapter 9(commencing Job Description with Sectio 1000)of 310.70.3 of the Beanesa nb ProfcNiom Cntle,.nd my license is L n Poll fnme.ndeffect. ;nz Le ore Lt..Al SKYLIGHT FINALEO nDeo: Chnua70r ARCHIIECrS DECLARATION �i 1 undersand my plans shall he used as public records SEP!1 O 2003 G Licensed Profmainml OWNER-BUILDER DECLARATION wB�e� I maxo .(Ston vital 11. uusin from the Canins10f1 :Any c Law for the BUILDING DING i a O which ire uiss,a Permian 11131.5,Business and professions Cale:Any city s county B�+YV Y u$r which rtquims a permit ro conation,also improve,demolish, fie a sig any ttmcmm k,Z fro Lpoor ou he its tensed p also pursuant thovisio s Of for Coit Permit m Ole a signed statement £ < (emenumeingwdpunuan,70th)OfDwinnanflheCOB10nessanfeawllw(GhodIC,9 Sq. Ft.Floor Area Valuation y $ that he is exempth Section t And Los basis n 3 of the Beg ed exempt Proon.Any vi Cod))or Net he is exempt therefrom wtl the baso for Ne alleged exemption.Any vinhdon of Secdon 7031.5 by any applicant fora permit subjects the applicant to a civil Penalty of APN Number Occupancy Type Am more Nan five hundred dollar(SSW). ❑I,ssawnerofthepmpeny,mmyemploymawithwgosa Neirwleeommnadon. will do the work and the auuetum is not intendedoroffertd Waste(Sm.IDN,Business 101 — FOUNDAWAPAd Inspections and Profeasinns Cade:The Co mactefs License IAC does nm apply to an Owner of property who builds or improves thereon,and who does such work bimselfor through his 102 PIERS awn employees,provided that suchimprovemems a re not intended or offered fmsale.If, lO3 — UFER however,Ne building or improvement is cold within one year of completion.the nwner- builder will lave the burden of proving ural he did not build or improve for purpose of 104 — REBAR saRJ� 105 - ANCHOR BOLTS Va.owmr of project progeny,.Business eadus And contracting wird licenced eonuwbn w Construct a door noapply to an romeny boom Code:) pro Caolaamri Li- 106 — SEWER & WATER chow Inco dos not apply a is comer of pwpeny who builds or improves thereon,and who contracts such projects withachnvanorl licensed purwmtmthe Convactar'a 202 - UNDERFLOOR PLUMBING Licenxe L.w. 203 - UNDERFLOOR MECHANICAL ❑lam exempt Dogs,See. B 9 P C for this reason 204 - UNDERFLOOR FRAME Owner e2iz:L-a Date WORKERS COMPENSATIONDECLARATION 205 - UNDERFLOOR INSULATION I hemby Airnm under penalty of Perjury oro of the following declal.tmos: 301 — ROUGH PLUMBING ave and will mainainacertificaanfConsent I.sof-insure for wn,ktracampen. 302 - TUB & OR SHOWER As provided fm by Section 311 of the Labor Code.for the perfonnanoe of the 303 - ROUGH MECHANICAL for which this Permit is issued. ❑1 have and will maintain Worker's Compensation Issusaom,as,m uimd by Section 304 - ROUGH ELECTRICAL 371,f the lwbor Code.for the penimen.ace of the work fit,which this Permit is issued. - 305 — FRAME My Workcr,Compensation Insurance caniermd Policy number art: 306 — HOLDOWNS Came - Poliry No.: _ CERTIFICATE OFEXEMPION FROM WORKERS' 307 — INSULATION COMPENSATION INSURANCE 308 - SHEETROCK or Ion.) section etion need not the Completed B the permit is for one hundred dollars 1$11) 309 - EXTERIOR LATH 1 cenify that in the perfarmarm of the work for which this Permit is issued,l elall not 310 - INTERIOR LATH employ any pawn in any manmrco as m become wbjm m the Workeri Compensation 311 — SCRATCH COAT Law,of C.lifomie.Date Applicant 313 - ROOF NAIL NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should 501 - FINAL ELECTRICAL ENERGY become subject 70 the Worker's Compensation proviciona of Ne Labor Code,you most pz forthwith comply with such provision or this Permit shall Mdeemed mvnked. 502 - FINAL PLUMBING ENERGY z� CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY 1 thereby'H kforwhichtmNaldartitsconsuunlon7, .) or the performanceof 504 - FINAL BUILDING ENERGY (Yr? the work for which this permit isissucd(Sm.3097,Co.Civ.C.) 505 - FINAL ELECTRICAL W o Le de's Name � z I4.Z.Address 506 - GAS TEST U O 1 comfy Nat 1 have rod this application end sant that the above infomuse.is 507 - FINAL PLUMBING correct I agree to comply with all city and county ordinances and sumwn laminting to V. building concoction,and hereby authrimrepraentffiW5OfLosCitytoenteruponthe F NhT. MEC CAL Lu above-mentioned pmNrLy for impeNon PurPowa a (We)egme 70 save,indemnify And keep harmless the City of Cupcnino against FI y liabilitieajudgmena,costs and expenses which may in any way seem)against said City 5% NG UZ in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: C WORKS Date SOURCE REGULATIONS. Re ;7 Sir i atureO ImanVChntrac Detc HAZARDOUS MATERIALS DISCLOSURE Type of Roof © Z Will the applicant or future building Occupant store or handle harardous material As defined by she Cupertino Mlost Code,emptier 9.12,cod the Health and Safely Code.Some 25532(x)? All roofs shall be inspected prior to any roofing material being installed. ❑Yoe No Will the applicant or future ppppppuuuuuu((((((IIIIIIJing Occupant use equipment m devices which If a roof is installed without first obtaining an inspection,I agree to remove s hovardnus air enmaminantsu rind by the Bay Arca Air Quality Management all new materials for inspection. ict7 ❑Yes ❑ 1 have mad the hasa m filar. aterials mquimments under Chapter 6.95 of the Califon .is Hcalthg:Safciy Code,Sections 25505,25533 and 2553/.l undersand that if the building does not currently ham a tenant that it is my responsibility in end fy f Occupant of the mqu' me awInchMust bc .issuance,of.CtoificateofOmupanry. Signature of Applicant Date Owner .uthoam ag)ni out) All roof coverings to be Class "B"or better