03070190l
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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONT=.R,ACTORINF,.ORMATION a
BUILDING ADDRESS:
EST7AT-136 ]DR
WEBER THOMAS B
PERMITNO03070190
OWNER'S NAME:
PERMIT ISSUE DATE
E:
SANITARY 0. CONTROL NO.
ITEC AINGINEER:
BUILDING PERMIT INFOBLDG
ELEL7 PLUMB MECH
I._
LICENSED CONTRACTOR'S DECLARATION1 hereby afrrm Thal I am Ilronsed under provisions of Chapter 9 (commencingoection 70(x0 of Division 3oflhe Business and Professions CsMe,and my license is"`
\'I ilr"��e
PATIO C ER/ O ' R, PV RAC�KK�Co.d
Lima Lic.0
_ ARCHITECrS DECLARATION
As sur
1 understood my plans Nell hc used as public records
1111.'[11-
Licensed Pmfesai... I
OWNER -BUILDER DECLARATION
I hereby affirm Nal 1 am exempt from N. Conba-ors License law for the
following mason. (Section 7131.5, Bualanm and Professions Cole: Any city or county
which requires a permit to convect, altar, improve, demolish. or mpair any structure
prior m its issuance. aim requires the applicant for such Permit to Glc a signed statement
Sq. Ft. Floor Area
Valu don
that he is licensed pursuant the pmvisinns or the Contncmr'e License Law (Chapter 9
(commencing with Section 71110) of Division 3 of the Business and professions Code) or
that he u exempt therefrom and the Amis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a North mbjects the applicant m a civil penalty of
nor mum Nan Gro hundred dellors (55003.
$I, m own- of the Property, or my employees, with wages a their Axle compensation,
101 — FOUNDAIK;Q?id Inspections
wlij'd0 the work, antl the swan. is net imended M rf,.d fondc(So. 70H. Bminme
And Pro ainkins Code: The Contactors License Law does not apply to an owner of
The
property who builds or themun,and whodms suchworkhimaelfor through his
102 - PIERS
own employees, provided that such Improvements arc not inended eroRcred for sale. if,
103 — UFER
however, the building or improvement is mid within orc year of completion. Ne owner,
builder will have the burden of proving that he did not Wad or improv. for purpeee of
104 — REBAR
sale...
105 - ANCHOR BOLTS
❑ 1. as owner of the properly amusine exclusively
and Pontessing with :)Tho licensedcontractorsto
construct the project (Sec. 7004, Business and Prof.uions Cope:) Tho Contractor's U.
106 — SEWER & WATER
cense lain does not apply to an owner or property who balms or improves themon.ad,
202 — UNDERFLOOR PLUMBING
who convects for such pmje-s with a contractor(&) licensed pursuant te the Contractor's
Licemelaw.
203 - UNDERFLOOR MECHANICAL
pI IandoSes. B & P C for th.reaAxn
204 - UNDERFLOOR FRAME
Owner I
205 - UNDERFLOOR INSULATION
WORKER'SCOMPEI ATIONDECLARTION
Ihereby arrestunder penalty OfPerjury eeeorthe mnowingdeclarations:
301 - ROUGH PLUMBING
ave and will maintain a CortiGcate or Consent m,elf-insum for Worker's Compen-
302 — TUB & OR SHOWER
satioo, m Provided for by section 37M of rite Iamr code. for the Perfornam. of rite
3 03 — ROUGH MECHANICAL
work for which this permit, is issued.
304 - ROUGH ELECTRICAL
❑ I have and will maintain Worker's Compensation Insurance. m requimd by Section
3700 of th. labor Code, for the performance of rite work for which this Permit is issued.
,30,5 — FRAME
My Workers Compensation lnsunnu carrier and Policy number art:
306 — HOLDOWNS
Grticr: CERTIFICATE OFEKEMMON MOM WORKERT
307 - INSULATION
COMPENSATION INSURANCE
308 — SHEETROCK
('Ibis Auction need not le completed Bthe lermil is for one hundred dollars 1$1(I(B
309 - EXTERIOR LATH
ear lesaJ
310 INTERIOR LATH
I certify that in the Pcrfenhance or the work for which Chia permit is issuers. I Ntll not
employ any person in any manneran m to become subject to theworkers'Compensation
-
- 311 — SCRATCH COAT
Laws
Taws of c.bmmi.. Da`App
313 - ROOF NAIL
501 - FINAL ELECTRICAL ENERGY
NOTICE TO APPLICANT: IL after making this Cenificsm of Exemption, you should
biome anhj.- to the Worker'. Compensation provision of the Lahnr Cod., you must
mrthwithmmplywithmehpmviatnnsmthis PermhmallWde.m.drevoked.
502 - FINAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY
503 - FINAL MECHANICAL ENERGY
I hereby affirm that there is a eonstructirm lending for the parforman¢of
504 - FINAL BUILDING ENERGY
the work Tor which this permit is issued (Sec. 3097. Civ. C.)
Lumber's Name
505 - FINAL ELECTRICAL
506 - GAS TEST
Under'Addreas
I cenlfy that I have feed this application and axle that the move Inronnatioe is
5 0 7 - FINAL PLUMBING
corm-. I agree m comply with alp city and county oNinantta and atsta text retailing m
Wilding mnswetion, and hembysmnorirc mprcxmnias of thiuiry to Poser upon due
athowWilding comaned proP.ny for by milhen purposes.
(WA) agree to save, indemnify and keep harmless the City or CUllprom.Zinan
FIN MEC CAL
F.'I
liabilities,judgment, costs and expenses which may to any way acerae against mid City
NGin
!jj
emisequcnce or the granting tar this permit.\APPLICANT UNDERSTANDS AND WILL CyMPLY WITnH ALL NON -POINT
Issued by:C WORKS Date — 2,4
REGULATIONS. nn ,/\ / / r
W Y1 PL/130
i tl�
Re -roofs
Type of Roof
Signeto,. of ApP te..VComommr Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or rotor. building Occupant stare or handle hawdous material
As defined by the Cupertinouy�spar Code, Chapter 9.13, and the Health and Safety
Code. Section 25532(n)?�
All roofs shall be inspected to an roofing material beim Installed.
Y g
❑rte -jabs
prior g
P P
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant orfuture Wilding «capantonquirom dordeviceswhich
hemmnmtaM
at, dcedbydue Bay Area Air Quality Management
all new materials for inspection.
strict?
❑Yes
I havereW the KAO terials requirements under Chapter 6.95ofdo, Califof-
nia Health & Sal.ty Code, Sections 25305.25533 and 25534.1 und.rsund thaz ifJe building
Jocs not currently have a tenml than It is my responsibility to Mary the aeupanl or the
.wmNma,l �p Pyrpli:Fu cenncemG�Occure ��
Signature of Applicant Date
— i `I ,J
All roof coverings to be Class "B" or better
Owns
?
oraulhmai,dAgent