00080046 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING nDDR6sg.}=:39 HAMMOND WAY_ �^�` �r1�0 r> SANITARYN00 LIGA'GION SUBMITTALDATE
OWNER'S NAME: I Is �h IL[JJ ILIVJ4YYfO016
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RCHITMT/ENGINEER - /' 6 .J� G ��— RULDINO PERMIT INFO
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Z O N LICENSED CONTRACTOR'S DECLARATION _
o z-❑ 1 hereby alrrm in.1 w licensed nnam provisions of Cheper 9 ronmmen=ing' Job Description
y w withSmtion7000)ofDivhours 3 ofthe Business arta Profttaiam Code,and my lietoaeis
in full force and effect.
arose Llumeclaaa uag POOL PAVILL_ION/173 SQ. FT.
b 3 u y Dete Com"Go"
E,is O Q ARCIRIELTS DECLARATION a -
a� f landercteed myplans shedbeuud upublic records -
d 'tensed Prier..usual
u1_'o OWNER-BUILDER DECLARATION -
C I hereby from the,I am exempt from me Contractor's Licenee Law for the
S following ou emt.(Section 703 IS,Business and profession.Code:Any city or county
Q which reyuuu a permit to Wratio m,ober.improve.demolish,or repair any oramen 5 Ft.FloorArea Valuation
prim to its isauenu,ilea requires Ne epplicentfoauch pemtiteEleaaigned atatemem q'
met he is licemed punuant m Ne previsions of the Comsat&License Lew(Chaps"9
(<u,heis ttemitngentim.and)omMisfrofmeBaemnenane,Anyorende)m APN Number Oecu an —
maa he is exempt therefrom end the Weis fits me ets the exemption.Any violation of p
Sermon 7031.3 by any applicant(m a pertni,subjects IW applicant to e civil penalty of -
s mens men nate Wndrnd dollus IE300).
I,as owner of de property,m my employmv with wage.m Neinole Compenation, 342 Inspections
do the work,and Nestrucmrc is not intmMcd ooRered fmsele(Sec.7044,Business
and Profession Code:The Conbacton.License law docs am apply re an owner of
fac"y he bullas or improve.,Wren,and who does such work him.elf or through 101 — FOUNDATION
W.own employees,Provided Out such improvements are no,handed or offered for -
We.l[howevem me building oimprovement i..oldwithin one yeerrefcompledon,the 102 — PIERS
•mor-wilder will have the Evident ofProving that he did"g wad or improve for Ism, 1@3 — UFER ..
r sal.). !�
❑Luo r of By,am exclusively convecting with,licensed contractors R,
constrict the project Business profession Code:)The Connunne.Li. i.04 — REBAR
se law Ia n bonen of proper who Wild,o improve.mart°,and! 105 — ANCHOR BOLTS
whocon sf h oAt.rnntr.emr(s)Iiceneed punuentmthe Conrracmte 0
106 — SEWER R• WATER
❑lame replan _ .B&P47fort ieressu,
- 202 UNDERFLOOR- PLUMBING
Owmr lK!*COe ONDECL °oN 203 — UNDERFLOOR MECHANICAL
I hereby Mem under penety M perjury one o following declarstinru: '
I have and will maintain aCarincate ofconent to self-more far Worker:Camper. 204 — UNDERFLOOR FRAME
aeon,mpravidedfor bySecure 37MofBan Labor Code,for the performer.ofine2@5 — UNDERFLOOR INSULATION
ti,
work for which this pemis i...ed.
r-1 I have used will maintain Worker's Compatiation Insurance.in required by Section 301 — ROUGH PLUMBING
37M of the Labor Code,to,the performance of me wok for which this arms in issued. — .
farm°a�r.�c��e`do{_I>awrmme=eni.PodyNornamW,are: 302 TUB R• OR SHOWER
CERTIFlCATE OF E%EMPDON FROM WORKERS' 303 — ROUGH MECHANICAL
,COMPrsNSATfON[NSUMNCE 304. — ROUGH ELECTRICAL-
(Thi,section rand not W completed if the permit is for me hundred&I[=IS 100) '
or hiss.) 305 — FRAME
Ioy.,that in the performance nrmewmkfor which this persnlorleas'Co. .. 306 — HOLDOWNS
not employer person in any mennr w ere m become subjecno me Workers'Compen-
Afi,hLaws of California Dae
Apdi=.nt 307 — INSULRTION"
NOTICE TO APPLICANT If.after making this Cerincee of Exemption,you should , 308 — SHEETROCK
become subj«uo the Workets Compematio.Provisions of me Laver Code.you must
for5hwim comply wire such provisions or this p.it"I W Seemed revoked. - 309 — EXTERIOR LATH '
z CONSTRUCTION LENDING AGENCY 31.0 — INTERIOR LATH
Q (hereby affirmmeat inert is a emostruce°n lending agency to, perf.s.of -
wokImisluchthispe list . (Sa.3097.Civ.C.) 311 — SCRATCH COAT
a4,i lander'.a > IandeesAddrName e.. 313 — ROOF, NAIL
w c 1 terrify that 1 have road dds application and state that the above information is 501 — FINAL ELECTRICAL ENERGY
0 z correct.l agree to comply with all city and county ordinances and state laws relating m -
'ding construction,and hereby summits representatives of this city to enter upon me g@2 — FINAL PLUMBING ENERGY
V Q and memicnedproperfmimpectianpurposes. -
w F e or ve,mdemoryand keepW"rle..the City ofcupertinoagaint 503 — FINAL MECHANICAL ENERGY
Q V babib at,,6i Ism17I eros which they in any wey ac Gr.against uid City
w iniom'a aftheg 'ngofthisp nil. 504 — FINAL BUILDING ENERGY
On AP .ICAN' DERSTA S AND WILL COMPLY WITH ALL NON-POINT
U z sou ERE.. - TIONS. 505 —FINAL ELECTRICAL
506 — GAS TE
sr ,Sig "aDO - Due /grv7,��() INRL BING
HAZARDOUS
V�
° HAZARDOUS MATERIALS DISCLOSURE
Wil byteCuperdemFurore building.,Chaptemrem Wntlle Health and Safety Re-roofs S@8 — FINA EL`AATfTG
n defined m the Cupertino Municipal Code,Chapter 9.12,e d me Health seta Safety
'cade,se=eanzss3z(a)? Q� Type of Roof 509 _ FINAL GRADE
°VCs 0 FINAL PLANNIT
Y - Will the applinnt or fuwre Wilding occupant use equipment or devices which - All roofs shall be s,ppsetee,dd �M�ggr� tg1�py o terial beim
I - amith undmaiirc°"uminentse. finedbythe Bay Area Air Quality Management installed. If a roo tnstttaIIA"t�4tti gPT i st"otifan nl g an inspection
` DisVim7
❑Yes
� I agree to remove all new materials for inspection. Applicant
s 1havereadth resmrialsr<quiiemsom,Me,Chaptnfi.95ofmcCali. Understands and will comply with all non point source regulations.
forma Health A, y C 'ons M05,23533 and 25534.I understand that if the
M1oilding dm m a em atit is my responsibiliryengify led mxupent
of me t metp m issuance ofa Cerifirmenf Occupatmy.
ore I -��
Date Signature of Applicant Date
owner r age
All roof coverings to be Class"B"or better
OFFICE