02040044 CITY OF CUPERT[NO x`10
BUILDING DIVISION PER MIT .CONI.RACTOI2 TN'�O ATN
BUILDING ADDRESS: PERMIT NO.
10110 N DE ANZA BLVD n,)nann44
R'S NAME: PERMIT ISSUE DATE
ST. JOSEPH OF CUPERTINO PAR SH
ONE:
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
ARCHITELT/ENGINEER: BLDG ELECT PLUMB MECH
C=
o O LICENSED CON RACIOR'S DECLARATION Job Description
e0 1 hereby affirm that 1 un licenced under provisions of Chapter 9(comeMln& P
with Section 7M)of Divisors 3 of the Busnw and Professions Code,and my license is
imfall to=Rodeaem NEW BLD 21. SQ. FT.
z License amLk.a
Contractor
Drum.ARCHITECTS DECLARATION PERMIT EXTENDE, ILL 4/09/03 .
�y 1 undersand my plans shall he used u public breads ✓ I ,
U ,1
Is Licensed Professionall
g
OWNER-BUILDER DECLARATION
4 f I horohy affirm that 1 am exempt from the Communes License Lew for the O "'
i o o
following (Section 703",construct.alaat and Pre.dmom Code:Any city er manly
$ which requires•permit re stheellen m naso deermitt or repair any structureant
tprior hat he its licensed
o,sm requires the amRcam for such permit w fact l U.
(Chument
0
(commencing
611amedpaa°nuoNepmvisoon3ClamBuhrmandPoselaon.CodM9 Sq.Ft.Floor Area Valuation
(comm I.Cont a Cameroon,
and
of but. or Claim eg a exa m t on.Aryan.Cola)of
Ns he la eanmpt rMmfrom and tit bu4 for the alleged mrmp0on.Any No1Nm of
Section 70713 by any applicant for a permit subject the applicant to a civil Penally m APN Number &Qy Type
not mart than five hundred dollars($500).
0 1,as owua of Ne pmpeny,ormy employees with wagesu theb role mmpenuli m,
willdo Rework,and the structure is notinunded or offered forsse(See.7040.BusinessRe aired Inspections
and PmfcWm Code:The ennmemre License Law don ret apply to an owlue of 9 P
property who builds or improves thereon,end who does such wank himself or through his
own employee°,proNded that uch improvements are notinualea aOEctedforssle.B, 101 — FOUNDATION
however.the building M impm rco ml is sold within on year of mmphmon.the.
builder will ban the burden of proving that he did not build or Impomm fee purpose of 102 — PIERS
103 - UFER
I,as overset of the property.am"elusively contracting with licensed Contract=10 10 4 - REBAR
..Met the project(See.7004.Business and Professions Cade:)The Contrmi U
wr -
eemeLawdoesnotapplyheanowMrofpropenywholuildsorimprovmtherein,and, 105 — ANCHOR BOLTS
who contractsfor such pmjecu with a eonuector(s)licensed pursues w the Contractors
Lleense Law. 106 - SEWER & WATER .
un me tun ec. .B&PCf.wsmum
�� S^� 202 - UNDERFLOOR PLUMBING
r ,te3 _ 203 - UNDERFLOOR MECHANICAL
WORKER'SCOMPENSATIONU kit. ATION 204 - UNDERFLOOR FRAME
1 y affirm under pcoa ty of perjury one of ole following deck atlons:
0lhave andwnlmainum-Cenlikneefcons.t W
roself- umfer WMkeracolnpen- 205 — UNDERFLOOR INSULATION
sstlon.u provldW(or by Secure 7700 of site taboo Code.(or are meformma of the 301 - ROUGH PLUMBING
work for which this permit Is issued. 302 - TUB & OR SHOWER
0 1 haw and will maintain workers Compensation Insurance,a required by Section 303 — ROUGH MECHANICAL
7700 of the Labor Code,for the performance of the work for which this room,is issued.
MyworkeraCompenstionInmtnmearrierandPoneynumberam: 304 - ROUGH ELECTRICAL
Carrier. Policy No.; 305 - FRAME
CERTIFICATECOMPENSATION INSURANCE WORKERS' 306 — HOLDOWNS
(Tbissectlnn need net beComphuad lfthe pemllt Is Inoue humbaddollan(5100) 307 - INSULATION -
MIw.)
_---- - . --------_ - - -- -- -- ----- - - -- --308--- -SHEETROCK-- -----
1 certify that In the performance of the work for which this permil is Imcd.I shall not 309 - EXTERIOR LATH
employ any person in any resonator u w become subject to the Worlamy CMepewlim
Laws of C.lifomla.Date 310 - INTERIOR LATH
Applicant
NUnCE TO APPLICANT.If.°Mr making this Oenifieare of Esemplion,you Mould 311 - SCRATCH COAT
become subject to the Worker's Compmumdon previsions of the Labor Cock,you mut
.J x forthwith Comply with men provisions or mit menu 0.11 be deemed mwkca. 313 - ROOF NAIL
tio CONSTRUC71ONLENDINOAOENCY 501 - FINAL ELECTRICAL ENERGY
H� 1homey afnnnthat them IsaConstruction lending agency,for the Performance of 502 - FINAL PLUMBING ENERGY
RS t the work for which this Permit Isissued(Sec.IIN7.Civ.C.) 503 - FINAL MECHANICAL ENERGY
W Q Landers Nwe
�Z Undoes Address 504 - FINAL BUILDING ENERGY
U p 1 comfy that 1 nave read tills application sad slam that sire above ufmmathm 1s5 05 - FINAL ELECTRICAL
ce
!I. correct.1 agree to Comply with all city and county cramenund mu,laws retail.&to
C building construction,and hereby euthorix representatives of this city menu,upon the GAS EST
W -hove-menuoned property for Inspection proposes. 07 F I
(We)agree w an,indemnify and trap harmless the City of Cupenim spinas
v) liabilities,judgments.costs and expectant accrue 5 t
AL
fJ In comequmce of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:5 Date
SOU B R�yULAT�ON Y 9( 1J ?l �� _
k,17,-,-� u�K -°T sly! Re-roofs
Wimatu o /Conu°cwr Dau 514 INAL PUBLIC WORKS
HAppltcanlAURDOUS MATERIALS DISCL.OSt Typeof RW62 - ROOF PLYWOOD NAIL
WIII the applicant m future buildinguPametore or handle havardows material
nand by me Cupertino Municipal a�`,Chapter 9.12.sad me Health and Safety 603 - ROOF BATTENS
Scam 255324)? All roofs s62Ok97eins j7riiDNtopa�ggfMgglaterial being installed.
CYm o
Wall dm applicant or Troon building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit havamnua olrcontm manes u hon 6y the BayAma Air QsmiRy Mangcment all new materials for inspection.
District?
CYcs u
1 have read the lumamms m-terlalarequimment underChapler6.95 of are C-litm.
nie Health it SmetyCodn.Swam 25505.25577 and 25534.1undcnund ars iflhe bulldin
deN rwl CY,M1nI he .tom,dant 11 is my memorability m wary IM a ml of
qui is w ch re t he r +riormi uuse-of s CcniOCase o u Date
Signature of Applicant
weer or orizctla cm Dau All roof coverings to be Class°Bo or better