02060185 CITY OF CUPERTINO, U
BUILDING DIVISION PERMIT ' CONTRACTOR INFORMATION:
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BUB'prgT A4DRDUMAS DR PERMIT N®2 0 6 018 5
,q"TANKIN K AND BAK Y APPLICATtrrYYf256rlf2002
PHONE: SANITARY NO. CONTROL NO.
ARCHITECI9ENGINLER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
In00LICENSED CONTRACTOR'S DECLARATION
�- 1 herehy affirm that I am licensed under provisions of Chapter 9(commencing Job Description
withScninn7lXXpnfDivisinn3nfNCBuxincssanJPmfcssinnsCmeanJmylian is ADD 876 SQ . FT.
e, in full Inmc and effect.
g? License Close Lic.N
Hrq Date Cimunchir
qua�a ARCIotTEDECLARATION
DF.OLARATON
�OyU Iundcrsland my plans shot lMUsed as public recnNs 3(
U 3t✓ Licensed Professional
t'l= OWNER"BUILDER DECLARATION
a <� 1 hereby al'lirm that I nm meant from the Contranor'a License Law for the $100000
1,E OO following reason.(Section 7031.5,Bacardi and Professions Code:Any city or county
2� which requires a pam,lt a,cunnrucl,alter.Improve,demolish it,repair any suucmm
prior h,its issuance,also requires the applicant I'nr.such permit to file a signed smtcmcnt
ISCthat he is licensed puts uanuo the provisionsof the Connector's License Law(Chapter,9 3S�912.940"AdtM Valuation
yh$ (commencing with Section 7(XN))nlrivision 3 of the Bus!ness and Promamons Code)or
_ that he b exempt thercfmm and the basis for the alleged exemption,Any violation of
Section 7031.3 by any applicant for a permit subjects the applicant to a civil penalty of 1 UAPNN Occupancy Type
not more Nan five hundred dollars($500). 102 - PIERS p y yp
❑ I,as owner of the property,or my employees with wages as their sole compensation,
Oil]do the work,and ON structure is not intended or offered far sale(Sec.70a4,Basin. 183 UPER
and Pro(cuions Code:The Contractor's License law does nota 1 an owner of Required Inspections
property who holds or improves thereon,and who daoasuch work himuto lfor Nmugh his 104 - REBAR 9 p
own employees,provided that such improvements arc not intended or offered for sale.If, 105 - ANCHOR BOLTS
however.the building or improvement is sold within one year of completion,IN OW@r-
builder will have the burden of proving that he did not build or improve for purpose of 106 - SEWER & WATER
rale')' 202 - UNDERFLOOR PLUMBING
l]sl,as owner of Ne propeny,am exclusively convening with licensed contractors to 203 - UNDERFLOOR MECHANICAL
convect Ne project(Sec.7Ma,Business and Professions Code:)The Contractor's Li.
cense Law does not apply to an owner or property who builds or improves Merton,and 204 - UNDERFLOOR FRAME
who contracts for such projects with a contraclor(a)licensed pursuam to the Contractor's
License Law. 205 - UNDERFLOOR INSULATION
� lemexcmpt under Sec. ,B&PCfor Nis rcuon 301 - ROUGH PLUMBING
r�0.wj e� ( (y Da 10 IS p2 302 - TUB & OR SHOWER
WORRER'SCOM DE CL ON 303 - ROUGH MECHANICAL
'�- - nandwaffm,tain acnally of ofCperjoyoneordient lf-insmin ingdarker'sns: 304 - ROUGH ELECTRICAL
❑en,Us and will for byneCion 37al or the Labor Code,foreeperform'sce of theompon- 305 - FRAME
section,as provided for by Section)71X1 of the Labor Code,for the performance of Nc
work for which Nis permit is came. 306 - HOLDOWNS
❑1 have and will maintain Worker's Compensation Insurance,cue required by Section 3 07 - INSULATION
37(X1 of the lahor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy num her am: 308 - SHEETROCK
Carrier: Policy NO.: 309 - EXTERIOR LATH
CERTIFICATECOMPENSATIONION INSURANCEORICI:Rs 310 - INTERIOR LATH
ohissecdon need nmbecompleml ifftramahieforonehundred dmlan(SNn) 311 - SCRATCH COAT
"ilea`) 313 - ROOF NAIL
I cenify that in the perm�A arta of the work for which Nis Permit is issued,I shall not 501 - FINAL ELECTRICAL ENERGY
empinyany posomwaq�rganefru+ a su "hL:.the Workers'Cumpcnsation
o ca mma;ntc-�f n �p 502 - FINAL PLUMBING ENERGY
Am oa should 503 - FINAL MECHANICAL ENERGY
N CT PPLICANf:1f,alter making Nis CeniEcate of Exemption,y
Notate subject to the Worker's Compensation provisions of the Labor Crude.you must 504 - FINAL BUILDING ENERGY
OO'Z'
forthwith comply with such provisions or Nis permit shall M deemed mvnked.
mareby CONSTRUCTIONLENDING AGENCY
505 - FINAL ELECTRICAL
FI forwhi hLhiNatthere itsconstruction leading agency lnnheperformance of 506 - GAS TEST
Ne work for which this parmitis issued(Sec.3097,Co.C.) 507 - FINAL PLUMBING
W Lender's Name
UU 0 Isndcr'1Addrtss 508 - FINAL MECHANICAL �.
O I cenify that 1 have read Misty and county
and sole that the above information is 509 - FINAL GRADE
W U bonding I agree w comply with all city and cuumy ordinances and stye laws relating e
Q building cnnswclion.and hereby authmircrcprescmmivcsnfNiscity menter upon Nc S FINAL PLANNING
show.-mentioned property ler Inspection purposes. 14 FINS
C>ti (We)agree to save,indemnify and keep harm less the City of Cupertino against
cel liabilities.judgments,costs and capenses which may in any way accmc against said City /p (�}i s
in consequenc
U at the gnd ng of this vor t.
APPLICANTOUNot RATAN Its AND WILL COMPLY WITH ALL NON-POINT Issued by: ing Date /l/U I/ VU/
SOURCE REGULATONS.
(B nz Re-roofs
ata of Applicam/Cnutaetor IDUt
HAZARDOUS MATERIALS DISCLOSU RE Type of Roof
Will Ne applicant or future building occupant store or handle hazardous material
-l..e"- s defined by the Cupcoino Municipal Cade.Chapter 9.11,and the Health and Safety
.41" Jr,Section 25532(x)'!
Dyes lot, All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes Dein
1 hove read the hazardous materialsoequimments under Chapter 6.95ofthe Califory
nixlicalth5 Safety CsNc,Sodons 25415,15533 and 25535.1 moderated Natif Nc building
ores not count have a tenant.Nat it is my resperian notify IM Occupant of the
requirements which muuMmct ptlormissuance oft Ccar mif 'cup erg Signature of Applicant Date
(� c `w All roof coverings to be Class "B" or better
cr of authorized agent Late