03010051 CI TY OFCUPERTINO � t��'' '`' �,{'♦ t'' fig^
BDII.DINC DIVISION PER MIT ,,N, "G,TQR�INFO,TtMATIO
BUIL DING ADDRESS: WATTS CONSTRUCTION PERMITNO.
1045
.R's NAME: 3941 RINCON AVE PERMIT ISSUE DATE
CALI FINANCIAL MANAGEMENT
NE:
SANITARY NO. CONTROL NO.
ARCHMCDENO1NEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
ow LICENSED LICENSED CONTBearRACTOR'S DECLARATION chnSJob Des9yyI l nnv,�
wire Sect on 7WorlIXMlnnf Dian tvlAloe3of the tee iteant I=licensed rprovisions ofud ProfcuimChapter
Col mY Ittnmb t+ Pu� "uALED
t� mmnrt�,nae �• GVZp-Sse� TENANT IMPROVEMENT
5ggMAY 1 9 2003
$ Dam ARCHRELTSIDECLARATION
1 uncle nal em shall he meal u public ranrN
sLL Lief wIOMI NVI�®���'
yp5 OWNER-BUILDER DECLARATION
NJ
a f 1 reason.
(Sun(Section n I em uempl Item Ute Cssion o Lkenec law for the
22 whichinrmoon. ht71Dsu Business and Profession Code:Any say Or County
$ paw t requhn•penh re cnutmeL aleg impmw,demolish,u at e.repairsig anyed nrumum
paw to issiensedp almmicdo the applicant far snhpcurr's MeasigrcAwemenl
< that hcIs encla; Il panoramic do of Divisio of thehe Budrwandcnxelaw(CMpter9 Sq.Ft.Floor Area $]-0b1®tlOn
$ tcomm is cumiNSenion70nd of basis far
of theegdnwmd Profwiovi Code)or
14
Net he 4 cumpt therefrom and Oro bu4(o thw alleged cacmptioe.Any violation of
Section 7071.5 by Any Applicant for a permit eubjecu the applicant to a civil penalty of 3%PD 70ii T8er0 0 Occupancy e
not more dun five hundred dollars($400).
P Y TYP
❑1,an owner of the Property,or my employes with wages as their sole compensation, -
will doarea warts.andtheswmure 6a humded or offered for mare One.70M,Business 101 —
And Prof" ...alCode:The Cmarectofs License law don not apply m an owner or 10 2 — PIERS
Inspections
property who builds m im W ores thneon,and who does.tech work hmewl f or through his
awn employee,provided that such improve ens,ma not intended Or offered fmsale.If. 103 — UFER
however,the building or Improvement is sold within on year or completion,the owner-
bulldar .will Nva the burden of proving that he did not build or improve fe,purpoe of 104 — REBAR
aI'')' 105 — ANCHOR BOLTS
❑1,u owner of the Property am exclusively sentencing with Banned!contnnms W
construct the project(Sec.70".Boalrcn and Pormdom Cade:)The camnemes U. 106 — SEWER & WATER
cetyLaw Lorsnot Apply WAnOwner ofproperty who Wild.orimpmwnmewan,and, 202 — UNDERFLOOR PLUMBING
who cantracss for such Projec s with a centnmorp)limned pursuant to the Comnnora
License Law. 203 - UNDERFLOOR MECHANICAL
am ucmptunder See. .BkPCforlhimreuon 204 - UNDERFLOOR FRAME
r Data 205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION
1 hereby Alarm under penalty of perjury on of the following decimation: 301 — ROUGH PLUMBING
I haw end will mainuln a CeNOcaue of Consent to self-Inmum fm Warier',Compcn- 302 — TUB & OR SHOWER
sedan,u provided for by Section 1700 of the labor Code,fm the per(omunce of the 303 - ROUGH MECHANICAL
tyre,for which this permit a issued. 304 - ROUGH ELECTRICAL
31aoowm�dwwo coao�on� romw�me�or �rc aarcnicnmuap<�iim�ea 305 - FRAME
MyW .Com a then Insurance carrier and Poliry,n�miierr am:.����� 306 — HOLDOWNS
PolicyNo.: "= 307 - INSULATION
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 308 - SHEETROCK
(Thier section ted not le completed if the permit is Per me hundred dollN(SIIX) 309 - EXTERIOR LATH
ormn) 310 - INTERIOR *LATH - - - - --
eeenlfymatermeInanyminneofthework en which tWhis permit l lona,Iermnm 311 - SCRATCH COAT
employ California.erwnIn Any murcrsoumbecame subject Wthe WorWn'Compewthon
Laws o(CaData
Applicant 313 - ROOF NAIL
NOTICE TO APPLICANT:If.&(set making this Certificate of Exemption.you Arnold 501 - FINAL ELECTRICAL ENERGY
become subject to the Worker's Compensation previsions of Ne labor Code,you mw
Jo forthwith comply with such previdomorthl.Permit shaamdeemedmwoted. 502 ' - FINAL PLUMBING ENERGY
Vy CONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL ENERGY
H— 1Wroby.M.ftdeeUsec.I..leading agency for the pefoone. 1 504 FINAL BUILDING ENERG
a� the walk fur which this permit hissued(Sec.307.Ca.C.) 505 - FINAL ELECTRICAL
W p Lender's Nemo
5Z u"deeAddmu' 506 — GAS TEST
U O I ceNfy that 1 Nes rad this Application and sale that the above information Is 507 ' - FINAL PLUMBING
iy coma lag=m comply with all city and county omimncem and mule law relating m -
0 building construction,ad hereby outhorise representatives or this city to enter treat the FIN MECHAN CAL
W aMve-mentioned property,for Inspection purpeea OR
Weioned accaw,indemnify arokeep humlw the City of Cupertino against 09 FIN
In ahulde,jadg e,camY Md expman which may in Any way smme against aid City 5, A NWG
V 7 in comequcnm of a gaming of this permit 1Y V
F7 PPLTCANT UN RST DS AND WILL COMPLY WITH ALL NON-POINT Issued by:5 WORKS Date f
CE RSOULA' Oi"
"lo b'3 Re-roofs
Sitnatm p muUCantaclar Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant m future building cempam ace nr Mndle huudom material
Brad by the Cupertino Municipal Code.Chapter 9.15.and the Health and Safety
Section]5552(.)7y� All roofs shall be inspected prior to any roofing material being installed.
❑Yes *e
Will the applicant or future building occupant um equilmtm or dcvicn which If a roof is installed without first obtaining an inspection,I agree to remove
It hosrdous air conumments as dcfind by the Bay Area Air Quality Management all new materials for inspection.
Wrier?
❑Yee *yr
t haw mW the hvwdammaterlal.mquimmenu underChaper6.95 of the Califor-
nuHaalthASActyCode,SwUmu25505.2555yandM55d.lundersmdmatifde Wilding
does not currently bow a Wants,that it is my responsibility m notify the oecuput of me
myulremcnu which mute be met prior u Issuance of s Certilkate of occupancy.
Signature of Applicant Date
Ownm ar mthode"a em Data All roof coverings to be Class"B"Or better