03050019 CITY OF CUPERTINO
BUILDING DIVISION PERMIT 4 C0 NTRAOTORINFORMATIQN
BUILDING ADDRESS: ""'00
ERMIT NO.
03050019
OWNER'S NAME: PERMIT 709AJFa ,7/2 0 0 3
SANITARY NO. 1 CONTROL NO.
ARCHITECYENGINEER: BUILDING PERMIT INFO
BLDG ELECT 0
PLUMB MECH
0 0 0
u o p LICENSED CONTRACTOR S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
4 with Section 7")of Division 3 of the Business and Professions Code.and my license is p� pp
In Lkfull scmel.naerre=t. Lien ADD 875 SQ. FT. /REMODEL FIoc7d�Y�EI�
F O Date contractor
ARCHnTCI-SDECLARATION APR 2 0 2004
C I understand and my plans shell used u public records
3yU
say
Licensed Pmfcuional
S OWNER-BUILDER DECLARATION
Comment's
om en BUILDING
<F I hereby a(Sec Net 1 aurin from the CmimsC's License Law for the ® L
00 followingremind.(Scedol 7031.5.on Buinasand w.deoli Coot:Any city structure 5$ which requires a permit re=naw=k alae impmw,demolish.t.nr mpaigned moment
prior m its i licensed
pursuant also nyuims tW applicant for such retort m Ole s signed vammat
4 (com endo withSenthcprovivioion3of Contractor's ndPourlaw(Chapmr9 Sq.F[.Floor Area $240V(§1N61ion
e5War W is excimiNSeeion rom and
of exactfroftWeged Business andon.Any via Code)of
.5F Nat he u essmpt therefrom and Ne hair far We alleged exemption.Any violation of
Seedin 7031.5 by any applicant for a permit subjects We applicant o a civil penalty of 3AFN Mithder 00 Occupancy Type
not mare Was five hundred dollars($500). .
❑Lu owner .and
propenyl oris utimmnftd ca with cages r Nei(sole rompenuness
will do We work.erode,The Contra nor in Lt. offered does Weapply 7Ua,Business —
and urty who
Code The Contractor's and
law dor Out apply f an owner is d Inspections
pnpenploy=, dso(improves thcmon,andwhod notin n&domseemdfor through his 102 — PIERS
hmadmncm,lWeeu,Ding or improvement
smhimpnwm within
mtiear ofcmofiemd Torula.!, 103 — UFER
however,We Wilding car impnwmenn is old within ort yearm mpro efor Ne owner-
W rider will new the burden of paving Nn he did trot Wild w improve far purpose Of 104 - REBAR
105 - ANCHOR BOLTS
1.u Owner of We property,am cWtua cly contracting with licensed conuaaorc to
coswct the project(See.70aa,Business and protrusions Code:)The Cumcmr'eu- 106 — SEWER & WATER
arm Law does not pply to an net ofyro,.y who Wildewsue improvthereon,and 202 - UNDERFLOOR PLUMBING
who conmcu forauehNSronoacmr(a)licensed purann t te an
hConumrs '
LKe�uw. i-projects�� 203 - UNDERFLOOR MECHANICAL
❑lam aempt�nea Sec .B&PCforthia muco 204 - UNDERFLOOR FRAME
ow (� Dam 205 - UNDERFLOOR INSULATION
Ili
/� t�WOIT-KERS OMPENSATION DECION
I hereby affim under penalty of perjury one ofN OOowing decimations: 301 — ROUGH PLUMBING
Z
and will maintain a Ceniicam of Consent to self-imam for workers Comped- 302 — TUB & OR SHOWER
action,m Provided for by Section 3700 of We IJWr Code,for the performance Of Ne 303 - ROUGH MECHANICAL
work ror cabala this permit is 304 - ROUGH ELECTRICAL
1 haw and will maintain Workces Compensation Iw(ance,u mquimd by Second
3700 of We labor Come,for We peRorronbcof the work for which this permit is issued. 305 — FRAME
My workers Compensation Insuranm ander and Policy number am: 306 — HOLDOWNS
caber. PolicyNo.: 307 - INSULATION
CERTIFICATE OF EMPI'ION FROM WORKERS'
COMPENSATION INSURANCE 308 - SHEETROCK
(1Tisacwiou need not W completed if the permit is for one hundred dDllam(SI00) 309 - EXTERIOR LATH
I merrily 310 - INTERIOR LATH
employ
Nat in the many summer
Wt work for which this reran is issued.1 shall not 311 - SCRATCH COAT
employ any petro anym nermumbcmmc subj=motM Workers'COmpcnsation
Iawsnfcaiifnmits Dam an 313 - ROOF NAIL
Applicant
NOTICE TO APPLICANT.If.after making this Certificate of Exemption.you should 501 - FINAL ELECTRICAL ENERGY
become Subject in We Workers Compensation provisions of the labor Code,you must
�z mMwith comply with such prdvisionsorthis permit shall the deemed mvaked. 502 - FINAL PLUMBING ENERGY
?O CONSIRUCf1ON LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
I bemhy aR(m0.1 then is a construction lending agency for We perfurmanx of 504 - FINAL BUILDING ENERGY
Z> We work for which rho;pemitHissued(Sec.3W7,Civ.C.)
Lenders Name 505 - FINAL ELECTRICAL
37 Q
Z)z Lndr'aAddrea 506 — GAS TEST
Q 1 cuddly Nat 1 haw rad this application and sum that the shove information is 507 - FINAL PLUMBING
y F' coma 1 agree to comply with all city and county ordinances and sate laws relating to
.>U building construction.and hereby mthorim repmamutives armhaiy to cnmrupnn We FINAL MECHAN CAL
=a alcove-mentionedpnpeny for iupecy a some a. 09 FI
(Wes)agree ro sew,indemnify and keep harmlcu the City Or Cupertino against
h Iiubilities.judgmcna,c$o(s�(ut and apcl"Which maymen way accrue against said City A NG
? APPLICANT UNDER- NOSgA' WILL COMPLY WITH ALL NON-POINT Issued by:5 WORKS Date
SOURC- EGUL IONS.
Re-roofs
inure ofooppbean O of Date
HAZARDOUS MATERIALS DISCLOS Type of Roof
Will dm applicant Or forum building occupant sena or handle hmardous material
u defined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
We. 0y.3smz(a)T All roofs shall be inspected prior to an roofing material being installed.
❑Ya '�Nn P P Y g g
Will the applicant or rumor building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
havardous air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
rstricR
❑Yes u
!have mad N.Wiculds. au" g3and!25underCharter rstand as if the Wilding I
itHcOIN@Seresy Codc,- oil Sll ami 35534.1 understand Was if the Wilding
dsra not cumently new s sena. at my possibility to mdly Ne occupant car We
n ireme..w ' V r I w.r.Ccnloc.mu44P.=. Signature of Applicant Date C,/
�
owmr m an ,mi,d agm. Data All roof coverings to be Class"B" or better V