03060049 CI-rY OP Ct1PERTINO
BUILDING DIVISION PERMIT CONTRACTWINFORMATION P.
BUILDING ADDRESS: PERMIT NO03060049 3060049
OWNER'S NAME: PERMIT ISSUE DATE
TONY qANrT4F.7
E: SANITARY NO. CONTROL NO.
ARCHITECnENGINEER: BUILDING PERMIT INPO
BLDG ELECT PLUMB MECH
jos,C LICENSED CONIRACI'OR'S DECLARATION CJ O O O
C I herchy affirm that I am licensed order provisions Of Chapter 9 unmmencing Job Description
iwith S))dua7("Pof Division 3 of the Buainevsand Prnfcssinna Codeand my license is
n full force and effete.
in
Class Lim.x NEW 1 STORY SINGLE FAMILY DWELLING
rIf Date Comment LIVING SPACE 2004 SQ . FT. /GARAGE 438 SQ. FT .
)—Wj ARCHITECTS DECLARATION
i 1 understand my plans shall w used as public rtt»rds
i
License]Pmfcssional
3 OWNER exempt BUILDER DECLARATION
1 a 0 1 hereby.(Seth thin 1 1. exempt from the f scions C's License Law for the
00 following rcamn. erten i]1131.4 Business and Professions Calc:Any city ns county
$fi which its requires issuance.permit to cnms;the paltet,plic improve,demolish,m mash any snupum
s�'^ pdormitswdpursu mgit the thovisio sOfant for such Petor a Licenfile se
Law(Chapter
2�0 that he(commencing with
pursuant 70th)of Division 3 theContractor
usinci's LirenulawsCode) 9 Sq. Ft. Floor Area Va W�a4M
2Fp (commencing with Semion](kq)nf Division]of the Businessand Professions Cn�c7 or
Z/�000
that he is exempt therefrom and the basis for We alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 39xY1��`b1�1700 Occupancy Type
rat matt Nan Ove hundred dallara DIM).
D I,as owner of the purperty,or my empluycu with wages as their sole compensation,
will do the work,and the swctum is not intended or offered for sale(Sec.70al Bust nus Reqquired Inspe on
and Professions Code:The Contractor's License Law does not apply to an owner or 101 — FOUNDAT.LON p
properly who builds o improves thereon,and who does.mch work himself or Nrnugh Ms '
own employees.provided that such improvements are not ntended or offered for sale.¢ 102 — PIERS Y/
however,Nto e building or improvement is sold within oyear of completion,the owner-
bander will have the harden of proving that he did aot wild or improve for propose or 103 — UFER
104 — REBAR
as owner of ct properly,,Beamsexclusivelynd competing with licensed eonuaor's to
aanaweune project(See.]B44,Brsmem and Professions eod):)The cnamamri u- 105 — ANCHOR BOLT&
cerise law does not aHdY to an owner or property who wilds or improves themon.and 106 — SEWER & WATER
who contracts for such projects with a contractor(s)licensed pursuant o the COa sicar S
License Law. 202 — UNDERFLOOR PLUMBING
❑1 am caa�m.!p�t'under Scc. B&P C far this rcuon
OwnergaG--.�`/=*V1 Dale/�Q�.__ICI-11 203 — UNDERFLOOR MECHANICAL
y4THRRKKgR'�IPENSATIOND}iLARATION 204 — UNDERFLOOR FRAME
Ihercby irff, funder penally or per;ury orcr Ne ronowirg de)Iaralira.: 205 — UNDERFLOOR INSULATION
I haw and will maintain a Ciotificate of Consent to ulf-insum for Workh"Comiam- 301 — ROUGH PLUMBING
smion,as provided for by Section 3700 of the labor Code.for the Performmcc of the 302 — TUB & OR SHOWER
work for which this permit is issued.
D 1 have and will maintain Worker's Compensation Insurance,as myuimd by Section 303 - ROUGH MECHANICAL
37W of the labor Circle.for Ne performance or the work for which this permit is isond. 304 — ROUGH ELECTRICAL
My Worker's Crmpenaadon Insurance carrier and Poficy number am: 305 — FRAME
Creno. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' 306 — HOLDOWNS
COMPENSATION INSURANCE 307 — INSULATION .
(This section need notes completed if the Permit is for one hundred dollars(SUIO) 308 - SHEETROCK
or less.) -
I)miry that in the Perfarmanec or the work for which this Permit is issued.I shall nut 3 09 — EXTERIOR LATH
employ any Person in any manner an as to become subjcetm tw Work.'Compensation 310 — INTERIOR LATH
Laws of California.Date
Applicant 311 - SCRATCH COAT
NOTICE TO APPLICANT:IL after making Nis CcnlOcac of Exemption,you shmW 313 — ROOF NAIL
became Subject to the Worker a Comfy nation provisions of the"hot Code,you must
7z mrthwith comply with such pmvisionsorthis permhshall the deemed revoked. 501 — FINAL ELECTRICAL ENERGY
z CONSTRUCr10NLENDING AGENCY 502 - FINAL PLUMBING ENERGY
I hereby affirm that dem is a emotmCinn lending agency for tM performance of 503 — FINAL MECHANICAL ENERGY
Y 7 the work for which this permit is issued(Scc.309].Civ.C.7
+u LendcrsName 504 — FINAL BUILDING ENERGY
Lender's Address
Z) z 505 - FINAL ELECTRICAL
1 ccrify that 1 have mad his application and sue Nat We above information is 506 — GAS TEST
y cartednc
.l agree to comply with all city and county oNtnacs and sum laws sclaling m
�U building construction.and hereby anthmiac repicunudses Of this City to crerupnn the FI&&ING
G
C abovomemitmed pmgm y for inspection purposes.
(We)agree m save,indemnify and keep harmless the City of Cupertino against 0 8 FI L
N
liabilities,judgments.costs and expenses which may in any way acerae against said City 44
;j,Z' in consegreaee.[,he granting or this permil. 5
" APPLICANT UNDERSTANDS AND WILL, OMPLY WITH ALL NON-POINT Issued by:5 Date
SOUR GGULATIONSSV /
�2sic1514
Re-roofs NAL PUBLIC WORKS
Signammor9 tic )too Date 6 2 — ROOF PLYWOOD NAIL
3AARDOUS MATER LS DISCLOSURE Type of Ro6o�
Will the applicant or future building occupant store or handle hvardous material 3 - ROOF BATTENS
as defined by the Cupertino Municipal Code,Chapter 9,12.and the Health and Safety 604 — ROOF IN—PROGRESS
Code,seal.25532ta? All roofs shall be inspected prior to an rooting material being DYa, t p p y g g installed.
Will the applicant or future wilding cesupart use equipment or devi¢s which If a roof is installed without first obtaining an inspection,I agree to remove
u ha„mous air contaminants u defined by the Bay Area Air Quality Management
District, all new materials for inspection.
�
Dyes 15<11
1 have read the wrumaus materials requirements under Chapmr 6.95 at the Udifor,
ria Health&Safety Code,Secdum 255115,25533 and 25534.1 understand thin if the wilding
dins not uncut are a tenant, at it u my resBpnihiltly m nuufy she occupant of the
mqulm cntswmebmu,twm dor issaancf,6r.cerdficateofoccupancy. Signature of Applicant Date
fffY�/// L— All roof coverings to be Class "B” or better v
Owner or atuVrrr7zdWW Dae