03030107 CITY OF CUPERTINO ' 'a '• 'wwvu+z�d N t�Es t• ' " ♦�%� ' '
BUILDING DIVISION PER] UT
BUILDING ADDRESS: PERMITNO.
011M A E: PERMR D
SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB - MECH
0,Z' LICENSED CONTRACTOR'S DECLARATION lob De' hors
1 hcrcby affirm that I am license under provisorm of Chapter 9(nmmcndng P
with Sectionl of Division 3 oflhe Business an ofealona Code.and my It...I.
irmlmro m kodbVMI REPLACE 2 WINDOWS
iLkenae Cla Lk.R. '
Dam cont r CONTRACTOR: ALEXANDER WERT COVN TRUCTION
ARCNRECTS DEC ON `�/�
1 den cad p1A spi he used eyp_ re 1 en a r, .
gYlll
.G Licensed Pmfc a
OWNER-BUILDER DECLARATION
CrairON
in Z 1 masa .(Brio that 1 1. exempt s an the Cnnvactoo Code:
nu Lew for tbo
O o following nnsnn. sewn t 7onstr Business and improve,
emnro Cnde;Any Illy m actum
Which rtyulres issuance,permit to ennmmcL alter improv,aeermit t car repair any atndme
�0^ pdormitsensedakumqulma theapplicantfor such permit toicese,Law statement
< that he(commelimnmdpurction70hcpravisinnsn the orbs usines'sLkmstlaw(Chapkr9 Sq.Ft.Floor Area Valuation
27,zC�
(commencing is exe exempt
Sectioor,and the
basis
3 note eg Business and on.Any vi Cndc)of
But Dc Is exempt Nertfmm and Ne Dasa far the alleged exemption.Any vioHtion of
Suwon 7031.5 by any applicant for a penal subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom than five hundred dollars($500).
❑I,as owner of dre property,m my employees with wages u delraole compensation, 35924019 . 00
will do thework.and thesvactum u not Intended unaltered fonate(Sec.7044,Business -
and Profession.Cade:The Contractors Limn,Law dam not apply m an owner or Required Inspections
property who bulldsur(mprotri demon,and whodmuuchwark hlmselforthrough his 101 - FOUNDATION
own employees,provided Net such Improvements we not Intended mo(femd for sale.If. 102 — PIERS
however,Ne building or Improvement issaid within one year of completion,the owner.
Wilder will have the burden of proving that he did not Wild or Improve for purpose of 103 - UFER '
El1.es owner of the property,am exclusively contracting with licensed convectors to 104 - REBAR
construct the project(Sec.7044,Business and Poofessions Cade:)The Commetnea U. 105 — ANCHOR BOL'L'S.
cause law does not apply to an owner of property who Wilds or improve themon,and, lO6 - SEWER & WATER
who contracts for such projects with a eomractorp)licensed pursuant to the Commetors
waaw.
❑' 202 UNDERFLOOR PLUMBING -
License
funder Sea ,BA PCIm Np moon
Owner Data 203 - UNDERFLOOR MECHANICAL
WORKER'S COMPENSATION DECLARATION 204 - UNDERFLOOR FRAME
Ihereby affirm under penalty ofperjury amofinefollowing dedmuona: 205 - UNDERFLOOR INSULATION
I hew and will mmmsp a Certacam of Consent to self-insure far Worker's Comport. 301 - ROUGH PLUMBING
station,u provltled for by Section 3700 of the labor Code,fm the performance of the 302 - TUB & OR SHOWER
work for which this Permit is issued.
❑1 have and will maintain Worker's Compensation Incomes,as required by Section 303 - ROUGH MECHANICAL
3701 of the labor Code,for the performance of the work for which this permit Is issue. 304 — ROUGH ELECTRICAL
MIy W"o�rke(�R{CnmppenwdypJneunmp taricnI tp' - O 305 - FRAME
C_JFIq. k�14U1.4Q.'E'-LL I•,�IL1I+ PoII
\�1// CERTIFICATE OF EXEMPTION FROM WORKERS' 306 - HOEDOWNS
COMPENSATIONINSURANCE 307 - INSULATION
(ITP uotim nerd not W completed if the permit is fm me hundred dollars($100) 308 - SHEETROCK
or leu)
-- I mnlfy that in the performance of the work for which this permit is aaoed.I shall not 3 0 9 -EXTER I OR -LATH_
employ any Person to any manner an as m Ivcoem subject to theworkere Compensation 310 - INTERIOR LATH '
Lew of California.Data
Applicant 311 - SCRATCH COAT
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you shoulJ 313 - ROOF NAIL
become subject to the Worker's Compensalian provisions of the labor Code,you mum
zO forthwith comply with such provisions or this permit shall he discover]revoked, 501 - FINAL ELECTRICAL 'ENERGY
n CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
r Iherthy aRmm thn then tsaconatruction endinpgcncy l'nr de performenm of 503 = FINAL MECHANICAL ENERGY
Si,>„ the work fm which this permit ts issued(Sec.3097,Civ.C.)
i q I nd,t'-Name 504 - FINAL BUILDING ENERGY
Z)Z l<nderaAaerons 505 - FINAL ELECTRICAL
J Q I certHy that I have mad this application and sou Nm sac above information le
y cornet.1 agree m comply with all city and county ordinances ane cute law relating to 506 GAS TEST
Ubuilding construction,and hereby authade:npresemativeiof Niscityloenurupnnthe FIN PLUMB G
H yabove-mentiunea property for Inspection purposes.
(We)agree m naw,indemnify and keep barmles.the City of Cupertino against 0 B FI L
r h Ilabllitlu.judgments,casts and expense which may In any say amue againsl said City
J7 Inco of the granting of this permit. 5
A APP ANT NDERS-ANDS AND ILL COMPLY WITH ALL NON-POINT Issued by:5 ING Date
SO CE LATIONS.
0 Re-roofs 514 NAL PUBLIC' WORKS
*N?.o ApplicsadConvactor Ga
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant er forum Wilding uacupwl store or handle herudous ma¢rial
as deOned by the Cupertino Municipal Code.Ch.pkr 9.13,and the Health and Safety
Code,Section zs3z(.>7
❑Yes `L No All roofs shall be inspected prior to any roofing material being installed.
�L
Will the applicant or future building occupant=equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t m.olous air cmmintrants ss defined by the Day Art.Air Quality Management all new materials for Inspection.
District?
❑Yca TNo
IhavemWNebumkn meterielamyulmmcnts unser Chapkrd.93of the Califoo-
ria o ASafuyCodc,Sccduna25505,25533.425534.1.n&.0 Natifthe Wilding
d not c rmmly have a tenant,that it Is my responsibility W notify the oecupsat of the -
quln which m Ihmct 'onnisasuanccofaCcmF'catd-FMPO , Signature of Applicant Date
cru authorized agent ate
All roof coverings to be Class"B"or better