03030119 CITY OF CUPERTINO r3 {eqr '�•r:9
BUILDING DIVISION PERMIT
BUIIDI NO ADDRESS: CAROL OZAK/BARRY WHALL PERMITNO.
OWNER'SNAM : GONGRESS P13 PERMIT
FS54tv E) -19
SANITARY @94OL NO.
ARCHITECTIENOINEER: BUILDING PERMIT INFO
BLDG ELECT FLUME MECH
30o LICENSED CONTRACfOR'SDECLARATION JobDescri tion O
iI hereby.flim that 1 am licensed under provisions of Chapter 9(commencing p
.� with Section TODD)of Division 7 of de Business and Pwfculom Code.and myl he=Is
h m
full forand of act. CprG'.,7
a'R4 ueenwClar. LIc.41 ADD SKYLIGHT f /
i Dau Contractor Z
ARCHITECT'S henDECLARATIONunderstand
1understand my phhi
os hit be ossa a public records
n G Licensed Professional
OWNER,co OWNER-BUILDER m Ce cors ON
I leroso a117m that 1 eat exempt from the Comform C a Llcenss law for the
o following ul Mason.(Section 7031.5,Business tand Profrssiuu Code:Any eaY or county
$ which Its Isar•Permit reenmwct,alter,improve,h rcurnitt ore a sig edny atnKtom
Sr tprior hat W I to armed pursuers
requiter tne inion or theCoh pemOuo Me uLaw(utemenr
a (co me cceroodpurction7 )PfDiviouoftheContractorkU¢nssiaw(Chaptm9 Sq.Ft.Floor Area d. Y Ion
ah (commencing with Secdon]OW)of DiWslonlof the Business and Proferdou Code)or YI-�
$ that ha it exempt therefrom and the bub for the alleged exemption.My Moladon of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
ro ,�p�7�qa]7Namaa t mane than five hundred dollars(S500). 3 x'07 9`11bFF 0 0 Occupancy T�ple
❑L u owmrof 0e pmpeny.m my employom withwagesu tiebr wlm mmpmnotim,
will do the work,mltusuucmm bmttmended mattered fertile(sec.7044,Business 101 — FOUNDPI 4iI�d Inspections
and Profession Code:The ComncwYs License law alma rot apply to an owner of
property who buildsor MpiovestMlmn,aMwhodoessuch workbimselforthough Me 102 — PIERS
mamemployces,provided thatmwh lmprevemrote meant lmmdedoroEentd Intend.It. 103 — LIFER
however,the building or Improvement Is sold within one year of,cmpletion,the owner-
builder .will have the burden of proving that hen did not build or Improve for purpose of 10 4 — REBAR
"Is.).
[3 1,u owner of the property.am exclusively contracting with licensed cenoacbn to 105 — ANCHOR BOLTS
routuct the project(See.7044,Business and Profusions Code:)The Contractor's U. 106 — SEWER & WATER
cense law done not apply to an owner of property who bullds or improves themon.and,
bhomnuam for such projects with amruactu(U named Parsers w the ContratnMm 202 — UNDERFLOOR PLUMBING
'axe' 203 — UNDERFLOOR MECHANICAL
Iam axemp Sec. Bk PCE rthls n
204 — UNDERFLOOR FRAME
°
WORKEKVOMPENSATIONDECLARAn 205 — UNDERFLOOR INSULATION
Ihereby ammunder penalty ofpeduryoust ofthe following deawauons: 301 — ROUGH PLUMBING
wand will malnulna CeNMteofeonssmto self-loom forWoheeaCwnpm- 302 — TUB & OR SHOWER
work for whhProvided
ch th sEpermit is bound.7�of uses Inbar cane,fm we performance at me 303 — ROUGH MECHANICAL
❑1 haw and will maintain Workees Compenuden Insurance,at required by Section 304 — ROUGH ELECTRICAL
5700 of the Letter Code.for the performance of the work for which this permit Is bound. 305 — FRAME
My workmen Comiwnution Insurance mauler and Policy number are: 305 — FRAMEHOLnONS
carder: PolicyNo.;
307 — INSULATION
CERTIFICATE OF fXFMPI70N FROM WORKERS' '
COMPENSATION INSURANCE 308 — SHEETROCK
or leoJ(rh auction need not he completed if the pumlt Is for one hundred dmlan($100) 309 — EXTERIOR LATH
1 ninny that Is
perfnggnnance of Werk for 91ch ibis
permh 4luved,p shall rot 310 .— INTERIOR LATH
employanype g'man n J e e/fVWI tmdu wormn'Comlronuuon 311 — SCRATCH COAT
r Lawn fC
^�I 313 — ROOF NAIL
N TO APPLICANT:JJ ager making this Cenitleate of Exemption,you should
btarom subjoatotheWod£s Compensation provisions ofNelahorCodc,you mum 501 — FINAL ELECTRICAL ENERGY
OZ forthwith comply with such Provisions;orthis Pemitshall bedeemed rmnked. 502 — FINAL PLUMBING ENERGY
T4rn CONSTRUCI]ONLENDiNOAOENCY 503 — FINAL MECHANICAL ENERGY
1E[r v., I hereby antro that Neu h a construction lending agency for the performance of
i , the wurkfor whmnthis pemithmmd(Sec.3097,Civ.C.) 504 — FINAL BUILDING ENERGY
0.W Q LendeerName 505 — FINAL ELECTRICAL
.: z Leader's Md.
U O I certify that I have reed this mtits
application and u that shove lnfmmbatlon 506 — GAS TEST
{g.
r. correct.I agree to comply with all city and county omirenm and main laws relating to 507 — FINAL PLUMBING
building construction,and hereby mNmire mprrxnudwa of this city ureter upon Ne
Wabove-mendoned property tan inspection purposes 0 FIN MEC CAL
t (We)agree to save.Indemnify and kap harmless,the City of Cupertino against 0 9 F I l
w Vl Ilabll I=.adgmenu.comaandex which may Iraq soy attmc getter Wd City
U t7�. mconsetuanmof Negreann of apemit. 5 NG f
APPLICA DERST ND WILL COMPLY WITH ALL N POINT Issued by: Date
SOUR O
3 Re-roofs
gm matApplineetrutm au
H RD°USMATERIALSDISCLOSURE 1 Type of Roof
Wllltheappll M Mfulure building oceupamstmcorhandlchamdous material
as donned by the Cupertino Municipal Cede,Chapter 9,13.and the Health and Safety
Cede,Section 23573(4)7
[Dy. T�No All roofs shall be inspected prior to any roofing material being installed.
WIII the applicant or future building occupant use equipment m tkvlcu which If a roof is installed without first obtaining an inspection,I agree to remove
aurenu air conteminanu u defend by tie Bay Arta Al,Quality Management all new materials for inspection.
ut7
❑Yes No
I hawread the hautdmun atesiahtmulmmonu underClupurti.95 of duCalifor.
nb Health h Safety Cada.ilmliotj 5505,75573 ens!25534.1 understood uulfde building
Jona not cu y
have tum(rl/tn9It b my responsibility u notify the mupant of Ne
myuirc pk a ptlorwInmceofaCe r3cauofOcu y. Signature of Applicant Date
/ 2 All roof coverings to be Class "B"or better
tt onuthodvcd err ate g