03010156 CITY OF CUPERTINO
BUILDING DIVISION PERMITCONT RACTORINFORM�ATION k
BUILDING ADDRESS: SMITHSON ROBERT C AND SUS PLI�kd ITNO.
10421 E ESTATES DR 03010156
wNER'S NAME APPLICATION SUB DATE
SMITHSON ROBERT C AND SUSAN 01/27/2003
ONIi: SANITARY NO. CONTROL NO,
ARCfI TCT/ENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
0 0 0 0
00 LICENSED CONTRACTOR'S DI!CLARA'I'[ON
F.
OZ p 1 hereby notion that I am licensed under provoci ns of Chapter 9(commencing Job Description
i Section with Sion Was))of Division 3 of me Business and Professions Cr and my license is
nmBruntandeff«L GASLINE TO STOVE/RECEPTICLFINA —R'D
o0� License Class Lica
Z—O Datc Contractor
= ARCHITECTS DECLARATION
a nt tn� 0 p [a
a I understand my plans shall bas e used PuMie necords NAR .6, 2003
xo su
=LLO� Licensed Professional
g
OWNER-BUILDERexemDBCLARATION BUILDING
<f 1 hereby altirm mat I an exempt Gem in tw CnLicenseor'a License taw for the
to
00 following reason.(Sermon 7131.5.Business and Professions Code:Any city or county
x$ which requires a Permit to ttmmrun,alter,improve,Jimmied.or repair any structure
tm—ZN prier to its issuance,also requires the applicant for such Permit it) a signed statement
o that he is licensed pursuant it)the provisions ofthat Contractor's License Law(Chapter 9 Sq. Ft. Floor Area $5110ation
rereF (commencing with Section 7gsp of Division 3 of the Business and Professions Code)or
ii $ mat he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Nc applicant to a civil penalty of
not more than Eve hundred dollars(55(1(x. be Occupancy Type
❑I.as owner of the property,or my employces with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale See,7W,Business
and Professions Code:The Conlfictor's License taw dres nut apply to an owner ofC
property who builds or improve thereon,and who deessich work himselfor lhmigh his 202 - UNDERF W Ul°1T311Vb
own employ=.provided mat such improvements ae not ntended or offend for nit.If, 301 — ROUGH PLUMBING
however,the building or improvement is said within one year of completion,the uwnet.
builder will have the burden of proving that he did not wild or improve for purpose of 3 02 — TUB & OR SHOWER
sale.). 502 — FINAL PLUMBING ENERGY
❑I,as owner of the pmpeny,am exclusively contracting wim licensed connectors m 5 0 6 — GAS TEST
consumer the project(See.AM4 Business sari Prufexsinns Code)The Comincmrs Lt.
Law Joe nor apply it)anowner ofproperty who Wilds orimproves themon.and 507 — FINAL PLUMBING
who contracts for such pmjccia with a cord aclor(s)licensed pursuant to the Commetor's
LIse law.
I
am excm ter C. B&PCImbism n
cr le / 27
WO C OMPENSATION DELL ION
1 hereby aRrm under penalty of perjury one of the following declarations:
I have and will maintain a Cenificau:ofConsent a self noun for Worker'.Compere
sation,az provided for by Section 3701 of me Labor Code,for thm
e performance of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as inquired by Section
3701 of me Labor Code,for me peRrt
nomes,of the work for which'his permit is issued.
My Worker's Compensation Insurance career and Pal icy number am:
Carrier: Policy No.: _
C17R'1'IFICAI'E OF EX EM MON FROM WORKERS'
COMPENSATION INSURANCE
leased Mas section read not w completed if on permit is for one hundred dollars 1$1aff
nr
I ccnifY thin in the pe Rprmancc nl th k far wM1ich This K I o issuctl.1 shall nm
employanypersn n c[.wyp9st c cs�h ccno to Wnrkers'Compcnsaden
Laws of Calf y ae/�6./ tel l //
AProlj�a 1 —
N F,f0 APPLICAA r If,after making this Cenillcae of Exemption,you should
became subject to the Worker's Compensation provisions of the labor Cn1a.you must
0Q forthwith comply with such provisions or this Permit shall deemed revoked.
z N CONSTRUCTION LENDING AGENCY
(-• Ihereby affirm mat there is a construction lending agency l or the performance of
ai rite worknr which this permit is issued(Se,3097,Ci,C.)
UW Lcndcr'1 Name
= Z Lenders Address
(� Q 1 certify that I have read this application and seta that the above information ria tion is
(L F^ building 1 ague el comply with all city and county ordinances of and state laws relating Rs
QU a Nice mentioned
for inspection
purposes.
sof thisci'y menter upon me
abovr(We) Ire propene for emnifymn keeps.
'U 4
(We)agree to sive.indemnify and keep harmless the City of Cupertino against V
F N liabilities.judgments.costs and expenses which may in any way acerae against said City
V z in amseyucncc of the grantin6 of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ION POINT
SCE IO Issued by: Date
T
41
�/ roof
S sere of ApphcandConna'mr 1 c Re- s
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building racupantstore or handle W mous material
as defined by the Cusenino Municipal Code.Chapter 9.12.and tw Health and Safety
'Me.Section 255321a)W
F)yes x1„ All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devises which If a roof is installed without first obtaining an inspection, I agree to remove
emit hanmous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Disnin'/ ��x
C3 Y. y No
I have read the haloodaus\materials requirements under Chapter 95 of the Cantor-
ria Health&Saltily Code,Sections 25NI5.25533 and 255341 understand mal if thr building
does no''a 'to y k dant, yyt it is y rc s m meloy to dly list r'cu�pY/an'of the
requiremen s w ' m Borto ise ce of a CeruBca'e Q�/ �/
SignatureofApplicant Date
ownerfir;mmari.en agent Dale All roof coverings to be Class "B" or better