03040120 CITY OF CUPERTINO �^t"
BUILDING DIVISION PERMIT ONTRCTUR IN'FOR' VIAIQN
Buy414W15UMAS DR TARN' S CONSTRUCTION PERMIT NO.03040120
l
N"TN K AND BAK Y 20540 MCCLELLAN RD PERMIT mu6T 24/2003
P (408) 873-9788 SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLD° ELECT PLUMB MUCH
0 0 0 0
30o LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm their sen therued under provisions of Chapter 9(commencing
wind 1C 70 ofDivialon3ofthc BAalncss d ,I ons Codc andmylicemeiA
In roll Ree �rc 3 REVISION--IN HOUSE USE ONLY
i a Llcen, C u.L."
qqq cannot NO NEW PERMIT ISSUED, ORIG. #02060185
3 — RCHIlECrS D f N
1 undernanJ my plan.mhdl W used m lie mcmd,
J /1
A G Licensed Professional
OWNEm exempt
DECLARATION
I orrery.(See on 11. exempt from the Comnamrs Code:A n C law for the
o G following Rmon.(Secuun 71171.5,Bosimss end Rvfesminm h, Any shy or county
o$fLi which RyulRs a permit re rnre the Alec Wpmw,dNmitM1,ar tepid,any statement 5'Sa
prior ht its issuance,also requires pre inions of fofmchpermluofdceeLaw(Chapte9 S Ft.Floor Area Ill tl n
$ Wrou...Ting wit pursuant m the of Division 3 thehe Bulntara License law(Chapter r Q•
(usm he
exe exempt
Scellant(a)rt! basis n5 nflWeged cumpton.Any viCode)of
.. But Section
7 exempt therefrom and l de Aper fm the objects
dutl exempnt to Any violation of
not more
a them, by sery applicant for•permit sobjects the applicant W a civil penalty of ppN Number Occupancy Type
not roma Bun Ow hundred dollars(5500}
01,as owner of the property.or my employou with wages u their sole compenuBon, 35926004 . 00
will do the work Intl theswclum is not intended oroRemd for Ago(SAM.7041,11,Rumina+roRequired Inspections
And Pmfesslom Code:The Conuacers License Law does not apply m an owner of I7
property who bulld+or Improves theon,and whodoessuch workhlmselforthrough his 101 - FOUNDATION
awn employees,provided that such Improvements arc not intended oroRend formale.if. 102 — PIERS
however.the building or Improvement is sold within one year of enmpleVon,the owmo-
builder will have the burden of proving Wn he did not Wild or Improve for purpose of 103 - UFER
+'le')' 104 - REBAR
❑I,u owner of Ne property am exclusively contracting with licensed conuanon In
construct Bus project(su.70sd,Busineu and Professions CmM:)The Contractor,Lb 105 — ANCHOR BOLTS
come Law does not apply to an owner of property who Wilds or improv thereon,rod. 106 — SEWER & WATER
who contracts for such projects with a COntrxcM,(Q licensed pursuant a the Comnamrs
License Law. 202 - UNDERFLOOR PLUMBING
❑ Iamexemptunder See. .B&PCfarlhiaro.son 203 - UNDERFLOOR MECHANICAL
Date
°t 204 - UNDERFLOOR FRAME
ER
WORKS COMPENSATION OFGI.SRAT
I hereby aflon Omer Nulty of perjury one of the following IMORIAliom: 205 — UNDERFLOOR INSULATION
I haw and will maintain a Cenifiue of Consentto ulf•Insum for WorkeM1Compcn. 301 — ROUGH PLUMBING
motion.m provided for by Sconce.7700 of the labor Code.for the Nrfarmence of the 302 — TUB le OR SHOWER
work( IOWANBORlglgsoed. 303 - ROUGH MECHANICAL
❑I Ave end w��B1 m�elnWn Wmker+Compensstlon lmurence.mrequlrtd by Seniors
7700 c Ifo'Cod.farihupedotmmceofineworkforwhi thispermiltsissued. 304 — ROUGH ELECTRICAL -
MyWork wti Inrrtnm caner m�.l�o7Pol nu 'ran: 305 — FRAME
C c C IFICAlE DF S%EMPfION FRO ORKERS' 306 — HOLDOWNS
'DV' 308
M 770NINSURA B 307 - INSULATION
'DV' ¢cl'��CBlflepermitbfnromhundndtlnllan(gIM) 308 - SHEETROCK
or las) 309 - EXTERIOR LATH
employ certify Thal in then performance of As work for which Nis Tenni)r issued.I sMll nm
any person wAs in in any Subject olneworten'Compema0an 310 — INTERIOR LATH
Liovs.
Lawaof California.Dam
Applicant 311 - SCRATCH COAT
NOTICE comesubject
APPLICANT:Works'.After Compensation
n r Rnifneof of Labor ion.you should 313 - ROOF NAIL
hecomehcompy the Worker's rovismpcmtlon provtsions of Bus coed rCrede,you meso
,JO forthwllhmmplywhnsuchpmv(siomorthis permllahJibcdcemednwked. 501 — FINAL ELECTRICAL ENERGY
�0 CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
(..4 Tho.byAM.des.ft.raeoonuclmnlending.,ency for the perfurm,nceaf 503 - FINAL MECHANICAL ENERGY
C� thet'sNfor which this Permit Issued(Sec.509'1,Civ.C.) 504 - FINAL BUILDING ENERGY
W Q
Lent's Name
az
Londe'a 505 - FINAL ELECTRICAL
Uo un fy WellMw Red this application a ona and that ft eWwinfomnionr 506 — GAS TEST
W C~ cancel.I agree to comply with all city and county ordinances and state law,gelding a
0 building construction,And hereby authorfits representatives or this city to enter upon the FIN PLUMB( G
W shave-mentioned pmNTly for inspection purpose,. V19�27
(We)agree to an.indemnify And keep lu rrieu the City of Cupertino against 0 8 F I L
taA liabilities udgmenu.cow end..remm which ropy In Any way accme against amid City 5
C) Inco veno oJJ.W�nminB of this pooh.
APP CA GNDEWANDS AND WILL COMPLY ITH NON POINT Issued by: INC, Date
SO R S. ,a NAL PUBLIC WORKS
Re-roofs
sl m of Ad`RuHAZARDOUS MATERIALS SCLOSURE Dam Type Of Roof
Will the applicant or future building occupant store m handle hevardous material
as defined by the Cupenino Municipal Code.Chapter 9.13.and tie Health and Safety
Code,Section 35572(.)7 �/' All roofs shall be inspected prior to any roofing material being installed.
❑Yes f(N.
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
telt bhunious alt contaminants m defined by the Bay ARA Alt Quality Management all new materials for inspection.
Dlnrict7
❑Yesu
I have nsei the hparWm,maerlah Rquinmenu under Cluper6.95 of de Califor.
ratsHc(Ith&S.Mt .SAL9mu 25505.35577 send 25534.1 undersand then iftht Wilding
does norm Mw i enanL Wel II m my n,ponsihllit m noufy ue occupant o We
Ryes m Must ft mama( cu LT. Signature°fApplican[ Date
All roof coverings to be Class "B"or better
o cr.r t ad. ate