03040072 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �,CONTRA,CT�OR�INFORMATION yrs
LD
BUIING ADDRESS: PERMIT NO.03040072
58:3 FELT= WY
OWN W NER'S NAME: PERMIT ISSUE DATE
?A.Cl�'IESANITARY NO. CONTROL NO.
ITECr/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
O O LICENSED CONTRACT'OR'S DECLARATION
:ce 1 hereby affirm That 1 am licensed under provisions of Chapter 9(commencing Job Description
ii,, with SRmmr70f0)afDi,iM,m3mfdm BasipEsandPofessions,Code.ad my license is
y inrml�CI., reef. / 7a 3 4 3 (� SFDWL-2 STORY �����®
Z Liccn lass Lia X
F w Date Cunuaclar ( _ ,P 0 3128 ' /GARAGE
££ ARCHITECTS RATIN LIVING SP 3128 /GARAGE 4
i 5< 1 understand my plan.,shall he used inTsIthfic mu,rds
tau
toy LicensedProfc3slon.I SEP i1 2004
g OWNER-BUILDER DECLARATION
<P I hereby affirm that 1 am exempt from be Contractor's License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
m which requires a pimmi m ennsovct.alter,improve,demolish,or repair any structure
i prior it)its issuance.also"mines the applicant for such permit to rte a signed statement
a that he is licensed pursuant o the provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area a 00
«� (commencing with Section 2000)of Division 3 of the Business and professions Code)or 4
F— that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 2831.5 by any applicant for a permit subjects the applicant to a civil penalty of 3�k�ILlprp�er 0 0 Occupancy Type
not more than five hundred dollars(5500).
0 1.so,owner of the property,or my employees with wages as their sole compensation,
will do the work and fee structure is not intended or offered far sale(Sec.7244,Business
and Professions Cade:The Ccomm oh Lt..law dna not apply On an owner of Required Inspections
property who builds or improves thereon,and who doessuch work ttimselfor though his 101 - FOUNDATION
own employees.provided that such improvements me not intended oroffered for saleIf,
102 - PIERS
however.Ne building or improvement is sold within one year of completion,Ne owner
builder will have file burden or proving that he did not Wild or improve for purpose of 103 - UFER
salt.).
❑I.as owner of the property,am exclusively contracting will licensed convenors to 104 - REBAR
comtmet the pmjecl(Sec.VOl4,Business and Professions Cotler)The Comacmr's Li. 105 — ANCHOR BOLTS.
cense law dura not apply to an owner of property who builds or improves,hereon,and. 106 — SEWER & WATER
who contracts for such projects with a contramor(s)licensed pursuant to tee Contractor's
1 ammasonlaw.
0lam exempt under Sec. .B&P C for this mon 202 - UNDERFLOOR PLUMBING
ate 203 - UNDERFLOOR MECHANICAL
137M
er WORKER'S COMPENSATION DECLARADTION 204 - UNDERFLOOR FRAME
Ihereby affirm under penallyof erjuryone offor following deelaraioms: 205 - UNDERFLOOR INSULATION
haw and will maintain a certificate ofCaucm to xlf.inme for Worker.Compen. 301 — ROUGH PLUMBING
n,az provided for by Senion PW of the IaWr Codc,for he performanec of the 302 - TUB & OR SHOWER
for which this permit is issued.
have and will maintain Worker's Compensation Insurance,az n uimd by Section 3 03 - ROUGH MECHANICAL
of he tabor Code,for he erformance of the work for which this permit is issued. 304 — ROUGH ELECTRICAL
waken Cutup nsadon msuanm artier and Poliicy number am 305 — FRAME
;:1yL Polis �a
/ CEF. IFiC TE OFE%EMPr10NWORKERS' 306 - HOEDOWNS
•••/// COMPENSATION INSURANCE 307 - INSULATION
,it IcssJ(TTissccfion need not he completed if thepermit is for one hundred dollars($100) 308 — SHEETRGCK
1 certify that in the performance or the work for which his permit is issued.1 shall not 3 09 - EXTERIOR LATH
employ any Person0 n az becomenany mannerselas come subject no the Workers Compensation 310 - INTERIOR LATH
Laws of Cslifmm..Date
Applicant 311 - SCRATCH COAT
NOTICE TO APPLICANT.IL after making this Ccniacate of Exemption,you should 313 - ROOF NAIL
become subject to the Workers Compcnsslion provisions of the labor Code,you must
�o forthwith comply with Bx
such provisions 501 - FINAL ELECTRICAL ENERGY
j z CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
I hereby affirm that there is a constoaion lending agency rte he performance of 503 - FINAL MECHANICAL ENERGY
].' the work fur which this permit is issuca(Sec.30092.Civ.C.)
^p Lenders Name 504 — FINAL BUILDING ENERGY
D Z ndersnaaress 505 — FINAL ELECTRICAL
J O 1 certify that I have read this application and sum min the above infomnion is
Z correct.I agree to comply with all city and county ordinances and sale Laws relating to 506 - GAS TEST
building construction,and hereby aufhorim represcmatives of this city to enter upon the
�U above-memimed properly for inspersion purposes. JIFIN PLUMB G
W (We)agree to save,indemnify and keep harmless the City of Cupertino again" 0 8 F I AL
fA Iiabilitim,judgmcnts.costs and expenses which may in any way accoc against acid City 5 ps�
J Z in consequence of the granting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WIT LL NON-POINT Issued by:5 TNG Date
S URCEREGU IONS. \/ o Us, Re-roofs 514 NAL PUBLIC WORKS
�Q2 - ROOF PLYWOOD NAIL
.care orA .a u ARD Dam b
HAZARDOUS MATERIALS DISCLOSURE Type of Ro
the appliwnlafuture building fecupmulmc or hanJlc hararduus material 3 - ROOF BATTENS
as defined by the Cupertino Municipal Codc,Chapter 9.12,and the Health and Safety 6 4 - ROOF IN-PROGI .E S S
Coast.Section zss3z(a)? V.
//IV� All roofs she I e inspecte prior to any ro0 mg material being installed.
Vcs V
Will the applicant or future buildingdecupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
if harardous air conaminants az cpncJ by the Bay Arca Air Quality Management all new materials for inspection.
Yrs V
1 haveret the hie ardnusomerials mquirenten¢under Chapter 6.95 ofthe Califon
ZnixHath&SafctyCwc,Smim.255B5.25533 and25534.1andcrstand thmifthc Wilding .
not currently haw a Tenant that it u my hespmeibdify m nudfy[be PeCtipant of the
mocom B which must Wme pfim issumccofa Ccrdf'aat of Occupmcri -a Signature of Applicant Date
Ownv au m nod agent ,m All roof coverings to be Class"B"or better