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03020035�z �O z>_ YA Z)z JO �F 4 J z CITY OF CUPERTINO9a� "�,eg ' y ^• "�' BUILDING DIVISION PERMIT CONTRACTOR INFORMATION Tb`9`5`V"ft ANZA-BLVD PERMIT NO. 03020035 o .I�FytjA'pA1E�I PERMIT ISSL6 rr, 7/2003 / dE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB L� MECH LICENSED CONTRACTOR DECLARATION 1 M1ehereby affirm that 1 am licensed underderprovisionsof Chapter Y (commencing Job Description p i�iih Scct 7 ))of0iviaion3af NCBusima andP f siuns Codc.andmyliccnuis mu n,re dermm' �O TI tL�� A ��® F af�y License. usn Lic. N f�`/2.9;o T ' Date / r iac • Vnaw ARCH CTS DEC ION 1 MAY 1 6 2003 1 understand my plans ahall he used as p c records Licensed Pmfessional OWNER -BUILDER DECLARATION BUILDING 1 hereby affirm that 1 am exempt from the Contractor's License Law for the following mason. (Section 703 1.5, Business and Professions Code: Any city or county which mquiru a Permit to construct, alter, improve. demolish. O repair any structure prior to its issuance, also requires the applicant far such Permit in file a signed statement that he is Reensed pumuant to theprovismm of the Contmem••s Lia<n:< Law (Chapter 9 Sq. Ft. Floor Area ��••3��I ion (commencing with Section 70)) of Division 3 of the Business and Professions Code) or Y Nat he is exempt Ncmfmm and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3$0t9�C 00 Occupancy Type not mom Nan firs hundred dollars (5500). P Y ❑ 1, u owner of the property, or my employees with wages M their sola compensation, will do the work, and the swemre is not intended or offered fur sale (See 701 Business 101 — FOUND){ j ssi and Profeons Cods: The Contractor's Lt.. Law does not apply m an owner or propenywhobuildsorimproashemo,and who doess«h work himselforthrough his 102 — d Inspections PIERS ownemployces, provided Nat men improvementsue not immoudWoraffered formic. If, 103 UFER however. the building or improvement is sold within one ycer of completion. the owner — builder will have the burden of proving that he did not build or improve for purpose of 104 — REBAR able.). 01, as owner of the pmfsny, am exclusively contracting with licensed contractors to 105 — ANCHOR BOLTS Construct the project (Sec.7(3,w, Business and Professions Code:) The Contractor's Li. 106 — SEWER & WATER cense Law does not apply to an owner of property who builds or improves themon, and. who contracts for such projects with a contractorN s) licensed pursuant to e Contractors 202 — UNDERFLOOR PLUMBING 01roLiccom exempt ❑ 1 p, exempt under See. . B & P C far Nis resort 203 — UNDERFLOOR MECHANICAL 204 — UNDERFLOOR FRAME nen Data 205 — UNDERFLOOR INSULATION WORK ER'SCOMPENSATION DECLARATION I hereby all under Penalty of perjury one of the meowing declarations: 301 — ROUGH PLUMBING 0 haw and will mainmmacaniicamafcoroentmulr-insure forWorkerseampen. 302 — TUB & OR SHOWER :aeon, as provided for by section 37M of the labor Code for the pertarmance of tnc work for which this Permit is issued. 3 0 3 — ROUGH MECHANICAL ❑ 1 have and will maintain Workers Compensation Insurance. u required by Section 3 04 — ROUGH ELECTRICAL 3700 mf NC Labor Calc. for the performance of the work for which Nis Permit is issued. 30-5 — FRAME My Workers Compensation Insureptt ca?j; and Policy nuber art : Carrier: Eva ier: fL. /t-tS.�"POI;ey No.: m-� 09 306 — HOLDOWNS CEURCATEOFEKEMPTIONFR WORKERS' 307 — INSULATION COMPENSATION INSURANCE 308 — SHEETROCK or msa)Ths section need not be completed if Permit is or one hundred dollars Rim) 309 — EXTERIOR LATH 1 certify that in the performance of the work for which this Permit is issued, I shall not 310 — INTERIOR LATH employ any person in any manner ao as mhecomc subject to the WorkersCpmpenatlon 311 — SCRATCH COAT Lawa of California. Date Applicant 313 — ROOF NAIL NOME TO APPLICART:If. after making this Cenificate of Exemption. you should become subject to the Worker'a Compcnution provisions of the Labor Cndc, you must 501 — FINAL ELECTRICAL ENERGY forthwith comply with such pnvisinna or his Permit ahae to deemed revoked. 502 — FINAL PLUMBING ENERGY CONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL ENERGY Ihereby whichaffirm that Nem its construction agency lnr the Performance of Ne work for which this at the is issued (Sec. ion le Civ. CJ 504 — FINAL BUILDING ENERGY Lend«:Name 505 — FINAL ELECTRICAL L eadcr's Address 1 mitiry Nu 1 have mad thia appecatinn and:etc that Nc above imformnwn is 506 — GAS TEST Correct. ) agree to comply with all city and county ordinances and state laws relating to 507 — FINAL PLUMBING building construction, and hereby awhoria representatives of Nis city to enter upon me alwvcmcmiuncd property for inspcceon pugwscs. — FIN L MEC ICAL (We) agree to save, indemnify and keep harmless the City of Cupertino against 0 — FI liabilities. judgments, costs and expenses which may in any way accrue against said Ci ty in consequence of the granting of this permit. APPLICANT 5j — NG / UNDERSTANDS NO WILL COMPLY WITH ALL NON -POINT SOURCE REGULATIONS. Issued b y: 4 — C WORKSDate Re -roofs amreo pplicanUenntaot r ate HAZARD USMATERIALS DISCLOSURE fWill Type of Roof the applicant or future building Occupant store or handle hazardous material as defined by Ne Cupertino Municipal, Code. Chapter 9. 12, and the Health and Safety Code. Section 25532(x)1 ❑Yea No All roofs shall be inspected prior to any roofing material being installed. win the a licam or f��`um builJin «eta ant use e rip s p equipment or devices which If a roof is installed without first obtainingan inspection, I agree to remove - P hazardous air contaminants as defined by the Bay Area Air Quality Management District all new materials for inspection. ❑Yes �No 1 have mad Nc Mmes tws materials mquimmcnu under Chapter 695 of the Califon niaHwlN A Safory Code, Sections 25515, 25533 and 25536. I understand Nu if Ne building docs not curemly Anse a tenant, that it is my ruWuihility m noely the rpcupant of the mwiremenuwhich most xmet priarprisauanceor. cemreateorCoo 7/o Signature of Applicant Dale I All roof coverings to be Class "B" or better osier ur.umoazed agent i,a