03100021 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACT6RINEORMATION '--
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BUILDING ADDRESS: """"03100021
ERMITNOO310O021
OWNER'S NAME: PERMITISSUE DATE
NE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
!Oo LICENSED CONTRACTOR'S DECLARATION
i ]obDescrip[ion
d F 1 hereby affirm that I em licensed under parviaiona of Chapter 9(cammencing
� W with Section 7IXkpor Division 3 of the Busine�Professions Code,end my license is
s in full fore o effect. w,
?5- Liman Lie.a 6 2 TI--DOCTOR OFFICE
FIN
Dam cantre CONTRACTOR: DREAMWEAVERS
DRQWI!L4TION
1
1,u Ion and my plans shall be used u public records DEC 12003
Licensed Professional
OWNER—BUILDER DECLARATION
F 1 mean 'ffi.Sec on I am exempt from the Cosinaors license taw for the BUILDING
p.'�D''p/�
o O following Rema($ecuun]1131.5,BusiMas and Professions Calc:Any city ser county u N
which ampares•permit m ermvua,arm,.narrow,demolish,ar rtPat,any nomwe
prior at its issumun,.Iso requires the applicant for such permit to Bit lc A signed summant
;Z< that he is licensed pun u'nt to the provisions of the Cmaneur's Lima.Law(Chapter9 Sq. Ft. Floor Area Valu t'
jl-Q (commencing with Section 700G)of Division Sof the Business and Professions Cade)or g00900
.. that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by am applicant for a pemtit subjects An applicant to acall penalty of 3�t��I lg>�gr0 0 Occupancy Type
not mart than Ave hundred dallara(3500).
❑I,As owner of property,or my employees with wages As their ale compensation,
will do the work,and the structure is not intended.,onared foheto(Sec.7044,Bnsineu Required Inspections
and Professions Cade:The Contractors License Law does not apply to in owner of p
property who builds or Improves Hereon,andwho coca such work himmirso through his 101 - FOUNDATION
own employees,provided Not such improvements are not intended or offered for sale.If. 1O2 - PIERS 0,Ne building or improvement is Bold within one year of completion.Ne owner
builder will have she human of proving that he did not build or improve for purpose of 103 - UFER
asle.). 104 - REBAR
❑1,a owner of the property,,Business exclusively Pro essi n&with:icched oonlrxemR m
codue.Anpplyas0AmumeofproeProfessionsCaA,improContrmmraW 105 - ANCHOR BOLTS.
Co.nte Law dasrouppytoan ithAorpropenywhe censedmorimpmvw Cormacond, 106 — SEWER & WATER
who contracts for such projects with a convasmrts)licensed pursuant m the Conuxemfa
Lt MaLow' 20.2 - UNDERFLOOR PLUMBING -
1 un exempt under Stt. .B k P C far this Rasmn
Dow 203 - UNDERFLOOR MECHANICAL
owner WORKER'S COMPENSATION DECLARATION 204 — UNDERFLOOR FRAME
I hereby affirm under penalty of perjury ore of the fallowing declarations: 205 — UNDERFLOOR INSULATION
haw
and will mountain a Cen[ficae of Consent m ser-ihm
ure for Worker.Copsn. 301 - ROUGH PLUMBING
an,as provided for by Section 3700 of the tabor Code.for the peRor n.ace of the 302 - TUB & OR SHOWER
work for which this permit is issued.
❑ I hew and will maintain Workers Compensation Insurance,as R lmnal by Section 303 - ROUGH MECHANICAL
3700 of the Labor Code.for the performmcc of the work for which Nis permit is Wad. 304 - ROUGH ELECTRICAL
My Wanton'.Co.pensaslonInsurance artier end up 11 umbar art: 305 - FRAME
Cpmery/
\/J CAUCH ICATEOFEXEMPTf0 WORKERS' 306 — HOLDOWNS
1V1 COMPENSATION IN URANCE 307 - INSULATION
(This section need not he completed film permit is ror one hundred dollars($1000 308 - SHEETROCK'
or Ices.)
1 certify Net in the perfmlmanee of dm work for which this Permit is island.I shall net 309 - EXTERIOR LATH
Lawaarc any eli o,pan mannerm obc subjceuo me worker' en m 310 - INTERIOR LATH
ApT9I 44— e� 311 _ SCRATCH COAT
Nor TOA LICA :It,arter making 0 a Ificatlof Eaemptmn,ynu should 313 ROOF NAIL
bee ubjeet m the orker's Compewtion provisionso(Ne Inbar Code,you muss
>,Z mMwith comply wthsuch provisions A,this annot hall xseemed nevokad. 501 - FINAL ELECTRICAL ENERGY
?5i CONSTRUCTION LENDING AGENCY 502 — FINAL PLUMBING ENERGY
I hcrehymMr.that dmrc its cohwcfirm[Audi.$ajancy Intone perfurnameo of 503 - FINAL MECHANICAL ENERGY
3i the work for which this permit h issued(Sec.3097,Civ.C.1
12 p Lumber',Name 504 - FINAL BUILDING ENERGY
5.5 z LcndeM1 Address -
,)p I certify that I haw read this application and sum that the above information Is 5 0 5 FINAL ELECTRICAL
wj� comet.I agree to comply with ad I city and county ordinances and state laws misting to 506 - GAS TEST
� building construction,and hereby authorise representatives of this city to enter upon the FI
'hove-mentioned property for inspection purposes.
(We)agree to sew.indemnify and keep harmers the City of Cupertino Against V55 *]]=tNG
F IL
il liabilities,judgments,costs and expenses which may in any way segue against old City
JZ in consequence of the gaming of this perm it.
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR rf�EGUL IOTtS. 4 7
/ wig /0 �A3 Re-roofs 514 NAL PUBLIC WORKS
Si aurcafAppl%H RDOUSMATERIAISDISCLOSU�EDam Type of Roof
Will tha applicant or future Wilding amupant seem or handle Imudous material
As dcftrted by the Cupertino Munscipal .Chapter 9.12.and Bm Health and Safety
Code.S cdon35532(4)7 a All roofs shall be inspected prior to any roofing material being installed.
❑Yes o
Will the applicant or future building Occupant into equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
aurdaus air contaminants as defined by the Bay ARA Air Quality Management all new materials for inspection.
C
13 Yea Wit
I haw mad the havardaus materials requirements under Chapter 6.95 of lite Califor•
nia Health&Safety Code,Sections 25505,25533 and 35534.I understand that if the building
docs not cuncn0y hew a tenan,:het h is my responsibility an Amity tho cecuprat of thc
reliireme ichm mctpsiormissuanceofaCcNIAir
t pancY Signature of Applicant Date
Air
Owner uthorimul enl C pats All roof coverings to be Class."B"or better