03040136 CITY OF CUPERTINO "`"$ €s
BUILDING DIVISION PERMIT " CONTRACT.OR INFORMA.TIQN
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gulyD3HTgDD19NRALLONE DR LEISURE LIVING & DESIGN IN ERMTN°03040136
UM"'CHARLES F AND CLARE T 1117 KELEZ DR PERMrr 8E4'nO/2003
NE: (408) 927-7117 SANITARY NO. CONTROL NO.
ARCHIECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LOp LICENSED CONTRACTOR'S DECLARATION
uI hereby affirm that I am IiavW under Provision"of Chapter 9(commcaing Job Description
towith Sauon'IOfXp of Division 3ofthc Bu,incss and Profcssiom Code,and myliccnu is r� �p /�
io full fa en cBiel.
,vyz Lieeue , 7 77d REMODEL E. PATIO ENCLOSURE
ZFp D O 'O Cont rr.o9 ry + 15 71
ARCHITE 5 l.4RATION JUN 1 8 2003
'ye W I understand my Plans shall be used as public accords JUN
p
;.N Licensed Pmfcssioml BUILDING
OWNER-BUILDER m Ce Conva°N
j.1 E I rimae .(Smt oro 11. exempt from the Contractor's License law for the
pO followingmama.(Saito 703 1.5,Boater. and Improve.
demolish,
Co de:Any city or county
$ which rtquiru a Issuance,aim re construct,tltee improve,demolish,nr a it i it any structure
primes its ated p,uorequires theapplicant for such pw.it to fileasigned,tatemcm
�� that he is located purmanun the provisions of the Conuxwr's Limnsc Law(Chapmr9 Sq.Ft. Floor Area $15 tion
or�C (commencing with Section 7000)of Division 3 of the Business and Profession Com)or
4
that be is exempt themfmm and the baso for the alleged Gumption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 6dff%U 1ib*cr0 0 Occupancy Type
M,fume than five hundred dollars(S500). P Y YP
01,uownerofthepmpray,mmyemployeeswithwrguut ftwiccompensation.
will do Newark and Ne suucmre is wt intended orolfered forage(Sec.7046,Business
and Professions Cade:The Contractor's Liame law dors not apply to an owner of 102 - PIERS d Inspections
property who builds or im proves thereon,and who daes,ah work himul r or through his
own4mployees.provided Nat such improvements tie not intended moReked for We.If, 103 - UFER
however.the building or improvement is mid within one year of completion.the owner.
builder will have the burden of proving that he did not Wild or improve for purpose of 104 - REBAR
01. 105 - ANCHOR BOLTS
❑1.uownrof thepm.71Nt,Bunesivnd contracting with li Thedmmrmmrsi- 106 - SEWER & WATER
construct the es not (Sec.nano weer of and Professions Cade:)Thews theamn. rad
whomaricontracts
such ply teas ithaofpmpartywho censedsorimptovu thereon.and 202 - UNDERFLOOR PLUMBING
who Cont2N for 3wth pmjeeef with a COnVacmr(1)licensed pmSWm m the CanVNIOYI
umoseLaw. 203 - UNDERFLOOR MECHANICAL
0 l am exempt under Sm. ,B k P C for this moron 204 - UNDERFLOOR FRAME
149, Dam-
S - UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION
I thereby affirm under penalty,of perjury one ofthe following declaration: 301 — ROUGH PLUMBING .
❑I hawand will mainuinacertifium ofComemmawnstre mrworter'lCmmpcn, 302 — TUB & OR SHOWER
.tion.ss provided for by See ..3700 of the labor Cade,ror Ne performance of the 3 03 - ROUGH MECHANICAL
work for which this permit is issued.
0 1 have and will maintain Worker's Compensation Insurance,as required by Section 3 04 - ROUGH ELECTRICAL
3700 of the LawrCom,for the perfmanstoe or the wart for which do,permit is iaued. 305 - FRAME
My Workeh�Co,/openain.hammers,carrier and Policy number art: 306 - HOLDOWNS
C sir:e74AI
O r- Policy f.�R.d/sr�eUy�
CERTIFICATE OF EXEMPTION FROM WORKERS' 307 - INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
len.)
(Thu scctim need not he completed if use,permit is for one hundred dollan($IM) 309 - EXTERIOR LATH
r310 - INTERIOR LATH
employffy
that in then any n arta of the work for which this the Worlocra'Conorsonsition
rl issued.l shall not
Laws Of
CaParsoninanymannermumbaomcsubjecttotheWwkcn'Campensalion 311 - SCRATCH COAT
Lawscant California.Dam 313 - ROOF NAIL
Applicant
NOTICE TO APPLICANT If,After making this Cenifica¢of Exemption.you should 501 - FINAL ELECTRICAL ENERGY
become subject in the Wohw's Compensation previsions of due lecher Code,you most
.Jaz foMwith comply with such provisions orthis permhshall the deemed revered. . 502 - FINAL PLUMBING ENERGY
z O CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
',e„tN+ Ihemhy aRirm Nal Nem iia conslrudinn lcndin mrtlte rfarm,m:e tr 504 — FINAL BUILDING ENERGY
g age^% p
IY > Ncwork for
ters, Nu permituusad(Sa.3097,Civ.C.)
Q Lenders Name 505 - FINAL ELECTRICAL
(y
az Under',Add. 506 - GAS TEST
U O I cenBy that I hive read this application and sane that the above m om stum is 507 — FINAL PLUMBING
correct.I agrem e comply with al]city and county ordinanas and sura laws relating to
Wilding construction,and hereby auN^nm representatives of this city in enter ulvm the
OU above-mentioned pmpertyfar inspetionpurposes. FINA MECHAN CAL
y (We)agree le save,indemnify and keep harmless the City of Cupertino again, O 9 F I N
F V3 WZ'Vz=D
ts,eostsmdexpenu which may in any way accrue agrin,uaid City 5 G
U z the grantinga .a Permit ISSUed b 5
^ DERSTAN AND WILL MPLY WITH ALL NON-POINT
AnoNs. Y WORKS Dale
Re-roofs
VCon rot � ate
HAZARD ATERIALS DISCLOSUR Type of Roof
licant or future building acupant store of handle huallousmaterial
u defined by the Copenim Municipal Code.Chapter 9.13,and the Health and Safety
o.Section 35533(x)7
CYu $ZrNt All roofs shall be inspected prior to any roofing material being installed.
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
ccoatt oormous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
D Yes
I thimpersol the hemardmu ,vc6.11 imponemcnu under Lltaptet495ofdim Califor-
0isHes Ill t r afetycadc,5ccd 355(15.35533and35534.1un&.dth.ifthc wilding
does n Qu oily haw a ten c et it u my rt ponibil'Ky iso notify the axupan of the
di e which ams Priprmam f,cerdf,ear«e �cy.G� Signature of Applicant _ Date
war, mia�it agicilt All roof coverings to be Class"B"or better