03100098 CI'T'Y OF CUPEWHNO "�
BUILDING DIVISION PERMIT CONTItAGTOR INFORMATION
BUILDING ADDRESS: BETHEL LUTHERAN CHURCH PERMIT No03100098
7
sR'S NAME: PERMIT ISSUE DATE
E: SANITARY NO. CONTROL NO.
A—HITECTIENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
0 0 0 0
s o p
LICENSED thatI CONTRACTOR DECLARATION
wF 1 barmy affirm that 1 am licensed anger provisions ar Chapter 9(commencing Job Description
IZjp with Section 7000)D1 Division 3mthe Bunincssand Pmfessionx Cndc,and my license is
in full force and crfect.
Licene Claw Lic.N PROJECTION SCREEN/ATTACHMENPIAj
p Oatc ContractorECL /Lp��
'dsry
ARCHITECTSallecr DECLARATION r'Pl
i k< 1 undersunJ my plans snail M used as public records
'os Licensed Professional JIL 82004
OWNER-BUILDER DECLARATION
<SI hereby affirm,hat I pm exempt from the Contractor's License Law for the
p o following rcanm.(Section 7031.5.Business and Profession Cade:Any city or county
j m which requires a Permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance.also requires the applicant for such permit to Glc a signed statement
?s< that he is licensed pursuant oamprovision ofBE,Contractor's Limuse Law(Chapter 9 Sq. Ft. Floor Area Va ua t n
_FC (commencing with Section 700[hof Division J of the B usincss and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of 3 7503022 - 00
Section 7031.5 byanyapplicamfora permitsubjccla the applicant macivil peraltytif APN Number Occupancy Type
not mom than five hundred dollars($5w). Pane Y YP
❑I.as owner of the property.or my employees with wages as their to compensa,inn,
will do the work,and the someone is act intended or offered r"rsale(sce.704,t,Badness 101 — FOUNDAI&;
and PP;dInspections
Pmfauions Code:The mr
Cmooc 's License taw docs not apply m an owner of
property who builds orimprons thereon,and who doessuch work hims<var through nig 102 — PIERS
win employees,provided chat such improvements arc not intended or offered for sale.If. 103 — UFER
however,the building or improvement is sold within one year of completion,the owner
builder will pave the burden of proving Nat he did not Wild or improve for purpose of 104 — REBAR
salt.).
❑1.as owner of the propert,am exclusively contracting with licensed conuaer..10 105 - ANCHOR BOLTS
consumer the project(Sec.70,14.Business and Professions Cade:)Toe Conmaori Ll. 10 6 — SEWER & WATER
ense Law does not apply to an owner of property who build&or improves thereon,and 202 — UNDERFLOOR PLUMBING
who contracts for such projects with a contractogs)licensed pursuant 19 the Cont&¢tors
ase law' 203 - UNDERFLOOR MECHANICAL
I an exempt ander see. .B&P e far this reason
_ `^� z e% ..�
Date /,/ 204 — UNDERFLOOR FRAME
WO ER'SCOMPENSATION DECLARATION 205 — UNDERFLOOR INSULATION
m
I hereby affirunder penalty of pejury ore of&I'll owing declaration: 301 - ROUGH PLUMBING
I have and wil l maintain a Certificate of Consent to gal binsum for worker's Compcm 302 — TUB & OR SHOWER
sation,as provided for by Section 3700 of the Labor Code,for the performance of the 3 03 — ROUGH MECHANICAL
work for which this permit is issued.
I have and will maintain Workers Compensation Insurance,az required by Section 3 04 — ROUGH ELECTRICAL
]700 of the Labor Code.for the performance of the work rtrr which this permit is issued. 305 - FRAME
My Workers Compensation Insurance carrier and Policy number are: 306 - HOLDOWNS
Cartier CERTIFICATE OF EXEMPTION FROM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 — SHEETROCK
was.)(Thlaseclum need mobs Complemd iftbc Mrenitisfnronchundmddollarsf51(1) 309 - EXTERIOR LATH
sir
I certify mm in the errilirparre of the work but which this permit is ivaed,1 shall not 3 10 — INTERIOR LATH
employ anype sex as me sub' vnthe Work 'Compensation 311 — SCRATCH COAT
Laws of Cantor n one
m
Applica t 313 - ROOF NAIL
NQfIC APPLICANT:If.after making this CedificateofExemption,you should 501 — FINAL ELECTRICAL ENERGY
becomes ect to the Worker's Compensmion previsions of the Lahor Code,you most
)z forthwith comply with such provisions or this Permit shall x deemed revoked. 502 — FINAL PLUMBING ENERGY
ZC CONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL ENERGY
I hereby affirm that more is a conswrdim lending agency lot the performance of 504 — FINAL BUILDING ENERGY
L' thc work for which this permit is mued(Sec.3007,Civ.CJ
snaer'sName 505 - FINAL ELECTRICAL
z Lcndar'sAddmas 506 — GAS TEST
O 1 certify Nat 1 ban read this application and sate that the above information is �—
y f—' carted.l agree to comply with all city and county ordinances and state laws rotating to 507 — FINAL PLUMBING
DU building construction.and hereby authonicmpresentatinsofthis city toenter upon the FI&&NWG CAL
above-mentioned property for Inspection purposes
tiy (We).,me to save,indemnify and keep harmless the City of Cupertino against 0 9 FI
liaJz in bolntscyuenfc of thegramts arns cabooid ses mn'chmryinanyway amsue againstsaid City 5 APPLICANT UNDERSTANDS AND WILL CO PLY WITH ALL NON-POINT Issued by:5 ORKS Date /
SOURCEREGUL 10
Re-roofs
awre of Appl icanUGmtncmr pate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or(marc building occupant store or handle haaardous material
as defined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
.Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes D�rva
Will thea applicant or build occu ant use e If a roof is installed without first obtaining an inspection,I agree to remove
pp g p equipment or devices which
hazardous air contaminants u dcfired by the Bay Arca Air Quality Management all new materials for inspection.
ulrict? &t
❑Yes
1 have mad the lurardnus materials mquimmcnU under Chapter 6.95 Df the Calirm.
nig Health Safety Crile,S¢Gon 25X)5.255JJ anJ 255]4.1 undersmnd Nat if the building
docs not currently have a tenant,drat it is my responsibility m nodly the occupant of the
re,marames whir mu met anoissti accrtlficamof Occuupona. Signature of Applicant Date
r to amnpriv. agent nate All roof coverings to be Class "B"or better