03080054 J
OR CUPER'l'INO
UILDING DIVISION PRRMITCONIRACI@I2INTORMATION
G ADDRESS: AMD CONTRUCTION & DEVELOPM � TN003080054
S NAME: 883 BRENT DRIVEPERMrr Issue DATE
UNCE ROBERT A AND 3
(408) 255-9911 SANITARY NO, CONTROL NO.
ARCtI ITECTIENCI NEER:
BUILDING PERMIT INFO
BLDGELECT PLUMB M[Cf
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i0Z' LICENSED CONTRACTOR'SDECLARATION Job Descrip ion
w II heJchy affirm that 1 am lice sed under provisions of Chapter 9(commencing
?i W wilt Sctp6n 1CN))uf Divi' n3ofihe Bu' ccsand Pr bbd C d dmylicenu is pp.�
<O, W211r andermet. L�CJCd�tp� ADD 37 SQ. FT. NALEO
� = Liccn¢Class ^^ Lic.A
-S�o Date Cantr Or MAR 2 3
ICARCHITES
dosl) ll(d my plans shall used as punt Rc records MAR
JyU
.off^ Licensed Pndcssinnal
5 OWNER-BUILDER DECLARATION BUIL�IiVG
1 hereby affirmthat 1 este exempt from the Conoanor's License Law to, be
o o rullnwing reason.(Section 1031.5.Business and Professions Code:Any city,,,County
i m which requires a Permit in construct.Aller,improve,demolish.or repair any structure545000
u¢i pan,ulitaCPU anc..xlsu.gvi..the applicant for such permit re rile a signed statement
<
that hcsliccnudpursuamanhcprnvisinnudthcContzctor,License Low(Chapter 9 Sq. Ft. Floor Area Valuation
2FC mmencin with Section 7IDD of Division 3 of the Business and Professions Code)or
3 s (`° g 36911028 . 00
Secti— Nat he is exempt therefrom and Bit,buil for the ct%dud exemption.Any violation of
notorethan56y hundred applicantforDDmmitsubjeav Nc applicant toaCivil penalty of ppN Number Occupancy Type
not more than Ew hundred dalton(5500).
o 1,As ow a,, fine property,army empluyces with wages As theirs-le compensation,
will do the work.and the sometime is not intended or offered for role(See 7W,Business 7 U I — d Inspections
and Professions Code:The Contractor's License Law docs not apply to an owner of 102 - PIERS p
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not lateral or offered for sale.If. 103 — UFER
however.Inc building or imprevement is said within one year of completion,the owner-
Wuder .will have Ins burden of Droving that he dm on baud or improve ter purpose of 104 — REBAR
salt.). 105 — ANCHOR BOLTS
❑I.as owner of the property,am exclusively contracting with licensee contractors to 106 — SEWER & WATER
construct the project(Sec.POda.Business and Froreasions Coel The Contractors Li-
cense law docs not apply to an Owner or pr°pcty who Wilda or improves themon.and. 202 — UNDERFLOOR PLUMBING
who contacts for such projects with a contractor(&)licensed pursuant.the Contractor's
Llcrosa taw. 203 — UNDERFLOOR MECHANICAL
t]I Am exempt under Sec. B h P C for this mason 204 — UNDERFLOOR FRAME
r Date 205 — UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION 301 — ROUGH PLUMBING
I hereby affirm under Penalty of perjury One of the following aeearstiono 302 — TUB & OR SHOWER
1 have and will maintain a Cenifale or Ci nsenl m self-insure for Worker's C°mpcn.
.anion,as provided for by Section 3700 Of the tabor Code,for the performance of the 3 0 3 — ROUGH MECHANICAL
work far which his reand iA,A,.cd. 304 — ROUGH ELECTRICAL
1 have and will maintain Worker's Compensation Insurance,u required by Section 305 — FRAME
37M of me Labor Code,for ore purormance of the work far which mit permit is issued.
My Worker s Compensation hounnce carrier and Per icy number are: 306 — HOLDOWNS
Caner. Policy No.: 307 - INSULATION
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 308 — SHEETROCK
This section need not roc completed fine return is for one hundred dollars(Strait 309 — EXTERIOR LATH
°(1055') 310 — INTERIOR LATH
1 ardry mat m rhe x r° Ice of rW work for which mit perm,,is isspea,1 span nm 311 — SCRATCH COAT
cminds ypearm nnersn cam a o kers Compensation
Laws of CebforniarDa 313 — ROOF NAIL
Applicant .� fl,•
NOfIC'�Qn\tT(IO APPLICANT:If,afar making this Ccnifica.of cmption,Yau should 501 — FINAL ELECTRICAL ENERGY
becmp Ajet,la the Worker's Compensation previsions of the labor Code,you must 502 — FINAL PLUMBING ENERGY
J z rannwo comply with such provisions or this Permit&hall he deemed revoked.
zo CONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL ENERGY
�-. 4 I hereby affirm that them is a conssmctinn lending agency tar the Knormanccof 504 — FINAL BUILDING ENERGY
D; > be work far which thin pe.it isissued(Sec.3097.Cis.C.) 505 — FINAL ELECTRICAL
m p
underaN. c
UAddm 506 — GAS TEST
G
Under Address
UO 1 certify past 1 have read this application and sure that the above information is 507 — FINAL PLUMBING
(—' corms.)agree.comply with all city and county ordinances and slate laws relating to
building conawnion.and hereby authoriser.pacentatiws Of this city to enter upon the FIN MECHAN CAL /IIT
W above-mentioned Propertysaw for inspection purposes. O 9 FIN
(We)agree to ave,indemnify and keep numless the City of Cupertino against
F' taA liabilities.judgmena Costs and wrens.which may in any way aeemc against said City 5 A NG
V z in 1OnuWencc ser gran ting of this t.
APPLICANT an AN IL OMPLY WITH ALL NON-POINT Issued by: WORKS Date
SOURCER LATI /2
e-roofs
i gnat p,I,C.n ZAR c US ATERIAIS DISCLOSURE Date Type of Roof
Will the applicant urfu ding uecupans smrc or handle bmaNuus material
s defined by tic Cufanin° Municipal Coac.Chapter 9.12,and the Health and Safety
Section 25532(a)p All roofs shall be inspected prior to any roofing material being installed.
❑Yes yNo
Will the applicant or rove.building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
,n W,Ao us air contaminator as deracd by the Bay Arca Air Quality Management all new materials for inspection.
D1tict1
❑Yes l�f Nu
I have maJ me Nnusmaterials reyw ¢nuunderCWp06.95oftheCelifar-
niaHcalNKSafcryy a do.255115.155 van 355.W.I sea&_ adtheaRthc Wilding
docs nm currcntlJ/nav Nat It I& ) ex s M1ilitY l,,,,only the a<upnl of the /
.yui.mcnu n as. cc r.i u r' n.araBateoraapari��2 igna[ure of Applicant Date
All roof coverings to be Class "B" or better
Own Ura or,.d agent Dam