03050063 CITY OF CUPERTINO '^'
BUILDING DIVISION PERMIT ^yCONTRACT0 INFORMATION .
BUILDING ADDIUMS: PERMIT NOb 3 0 5 0 0 6 3
UAMMQN�) WAW
.R'S NAME: PERMIT ISSUE DATE SCOTT F KATHRYN 14C)TIMITON 19
12
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
fop LICENSED CONTRACTORS p DECLARATION
C I hereby affirm mal l am licensed under provisions of Chapter 9(commencing Job Description,
U winll fts nTdeffec Division Jof me Business and Prufcssiuns Cook,and MY license is
n in full fon and effect.
i'in ueenxClass Lie.« LANDSCAPING FRONT YARD
-`❑ Dam Conlactor DECLARATION ARCHITECTS DECLARATION
u1 understand my plans shall he used as public records
gQ� Licensed Pmfcuional \
` 3 OWNER-BUILDER DECLARATION
s x 1 herehy effrm mat I em exempt from the Contraction's License Law for the '
no following reason.(Section 7031.5.Busineas and Pmressions Code:Any city or county
5$ which requires a permit a+cnnstrw:t,alter,improve,demolish,or repair any.haetne
poor to its issuamc.also requires the applicant for such permit to rile a signed statement
£ '
that he is licensed pursuant to the Provisions of dhe Contractur's Liccuse Law(Chapter 9 Sq. Ft. Floor Area L::,EValuation
y (commencing with Section 7(00)of Division 3 of the Business and Professions Cola)or
i $ Nal he is exempt therefrom and the basis for the alleged exmpd on.Any violation of 34258004 . 00
Section 7031.5 by any applicantfora permit subjects me applicant to a civil penally of APN Number e Type-
M.,more man Eve hundred doll..(5500). y
0 h as owner of the property,or my employees with wages as their sole compensation,
will do me work,and the suucmm is not intended or offered for sale(Sec.1044,Business 101 - FOUND
and Professions Code:The Communes Liceme Law dans not apply a an owner of d Inspections
property who builds or improm thereon.and who does such work himselfor through his 102 — PIERS
own employees.provided%at such improvnmcnm are notimendedaraBered forsale.If, 103 — UFER
however.the building or improvement is sold within one year of completion.thc owner-
Wilder will have the burden or proving that w did not wild or improve for purpose of 1 04 — REBAR
;sv � 105 — ANCHOR BOLTS
®11 as owner of me Picin y,am exclusively contacting with licensed canuacto.lo 10 6 — SEWER & WATER
construct the project(Sac.7044.Business and Professions CodeI The Cotonou's Li-
Cantu,
caLaw does
onot
nplyroan awn<r ar propemy woo wflm or impmam.neroon.,nd 202 — UNDERFLOOR PLUMBING
ply toa winecontnmur(.) ho Wil pursuantton<Coney.and
Lice.law. 203 — UNDERFLOOR MECHANICAL
0 l am exempt un der S ,B&PC far Of.reason 204 — UNDERFLOOR FRAME
�tiK--ems Dale b l9 6
WORKER'S COMPENSATION DECLAfawpq. 205 — UNDERFLOOR INSULATION
I be.by a)Rtm under penalty of perjury aoe of the ka Ing daclaruion:: 301 — ROUGH PLUMBING
❑Iban and will maintain a Cenmeam oreoment to se04nsure for Workers Conepcn- 302 — TUB & OR SHOWER
saloon,as provided far by Scam 37M of dm labor Code,for to,performance of nc 303 — ROUGH MECHANICAL
work for which this permit is issued.
0 1 have and will maintain Worker's Compemation Insurance,as required by Section 3 04 — ROUGH ELECTRICAL
37Mcrone lawrCode.far ft colormxaccofthe work for which this pemrhi.issued. 305 - FRAME
My workers compensation lnxraree canis and Policy number are 3�6 — HOEDOWNS
Cartier: Polity No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 — SHEETROCK
or Msa)(Ods section need not W comPlmmit ed if the peris for on hundred dollars($Ida)) 309 — EXTERIOR LATH
I certify that in to,performance of the work for which this permit is Issued..shelf not 3 10 — INTERIOR LATH
employ any m any manner as as w become subject o the Wurkces Compensation 311 — SCRATCH COAT
Laws of Calif D
Applicant a— +u 313 — ROOF NAIL
NOTICE TO APPLICANT.If.after making this Ccnifcam Of E.cmption,you should 501 — FINAL ELECTRICAL ENERGY
beton s jcct to the Worker's ComPcmation provisions of the Lawr Code.you must
.J� mon amplywim.ampmvhiamorthis Permit xnanbedeemed repted. 502 — FINAL PLUMBING ENERGY
'z r CONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL ENERGY
1 hereby F kfarwheRrmnnncreisa (See W7,Cingagencylonheperformanceof 504 - FINAL BUILDING ENERGY
a� the work fur which this permit is issued(Sea.]091,Civ.C.)
y q Lemli Name, 505 — FINAL ELECTRICAL
z Lender's Address 506 — GAS TEST
U O 1 terrify that I have read nil application andre star nc aW,,Information is
D. F cancer l agree 10 comply with all city and county ordinances and state laws relating to 507 - FINAL PLUMBING
0 U w;ldingconsmuction.andhorebyaothotmerepresentativesofth;scitytoenteruponthe — FIN L MEC ICAL
above mentioned pmperty for inspection purposes.
„ y (Wc)agree ro save,Indemnify and keep hay in an the City of Cupertino against 914
_ FIN
y in
judgmentse wailing ex p.meoomil. may in any way accrue against said City NG 1//Y
t.)z A APPLICANT
or UNDERSTANDS
Of this per m;.
^ SPULICEBEGULOATIONANDSAND WILL COMPLY WITH ALL NON-POINT Issued by: _ C WORKSDate
Re-roofs
gmfure of ApplicanUComraclor Date
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will rte applicant or fuwrc ,..ding wcupantsmro m handl.harallom mamoal
as de0ned by the Cupertino Mwi real Cate.Chapter 9.12,and the Health and Safety
Scetlan 23512(a)7
❑Yes No All roofs shall be inspected prior to any roofing material being installed.
Will thea aslant or metre uonn deco quip If a roof is installed without first obtaining an inspection,I agree to remove
pp 6 pant use a rotor or Devices which g p
emit hurardnm air c,ma mo anti a(left ed by the Bay Arca Air Quality Management all new materials for inspection.
District'
0 Yca Nu
1 have mad the harardeas materials requirements under Chapter 6.95 of the Califor- -
nia Health A Safety Cola Sections 25515.25533 and 25534.1 understand nut if the beim og
does not,urtenlly have a moan.nal it is my re,ormihility or noddy be tccupsm of thc
rtyuircmc hicM1 muss tpnurwtssuance ofa Ccrtihcam of Occup c.
Signature of Applicant Date
<t o�d seen. D,te All roof coverings to be Class "B"or better