03080174 CITY OF CUPER'1'INO as *>'� s •�«v' r k+ate ' " • "' %-
BUILDING DIVISION PERMIT CONTRACTORVIN IMATI®N i'
3
BUILDING ADDRESS: RYMIK DEVELOPMENT PERMITNO03080174
R'S NAME: PERMITISSUE DATE
PHONE: SANITARY 0. CONTROL N0,
ARCHITECfIENGINEER: BUILDING PERMIT INFO
BLDG EIEC! PLUMB MECH
i0o
LICENSED COiRACI'OR'S DECLARATION CJ O O
NO
I hereby affirm In.,I am licensed undo,provisions M Chapter 9(commencing Job Description
£i� with Section 7000)of In.,
3 alone Business and Professions Code,and my liccusr is
in full�qz
License cleans d effect. Lir.0 REVISION--IN HOUSE USE ONLY
i�'o Dam ContractorNO NEW PERMIT ISSUED/ORIG. #03030037
f w u 1 understand my plans 9 ARCHITECTS DECLARATION shall he used as public moods
spy Licensed Professional
I OWNER-BUILDER DECLARATION \
<S 1 hereby affirm that 1 am exempt from the Contractor's License Law or the \�
MO following reason.(Section 7031.5,Business and Pmfrsions Code:Any city or county
<m which requires a pc,mit to construct.alter,improve,demolish.or repair any structure
'!iy Priono its issuance,also requires the applicant fnrsuch permilm rile a signed statement
as that he is licensed pursuant to the Pmoiskns of the Commands License Law(Chapter 9 Sq. Ft. Floor Area VIluati
RFQ (commencing wi in Section 7")of Division J of the Business and Professions Coda tar 107
Oat he is exempt thcmfrom and the baso for the alleged exemption.Any violation of
Session 7031.5 by any applicant for a permit subjects the applicanno.divot penalty of
na,seam thea BK hundred dollars($500). - - -- - 3 2�$� 91�@r0 O --- - Occupancy P Y Type ----
❑h as owner of the PmPcny,or my moploycu with wages ss their axle compression,
will do the work,and the suucturx is not intended or offered for sale(Sec.7094,Business
and Professions Code:The Contractor's License Law docs not apply to an owner of Required Inspections
property who builds or improves thercan.and who deassuch work himselfor Nroughhis 101 - FOUNDATION
Own cmployca,provided dsmsuchimpmsemens arenotimmndederaffered formic.If. 102 — PIERS
however.the building or improvement issold within one year ofcomPletion.thrtomau-
builder will have ths burden of proving Wt he did not Wild or ho pmo,for purpose of 103 - UFE R
sale.).
1,as uwact of he propony,am exclusively contracting with licensed convectors to 104 — REBAR _
construct the project(Sec.7694,Business and Profcsa'ons Code:)The Conuactori Li. 105 — ANCHOR .BOLTS.
cense law docs not apply to an owner of property who builds or borrows Merton.and
who coronets for such pmjecs with a convacmr(f)licensed pursuant to the Contractor's' 106 — SEWER IS, WATER
[11.ase' 202 - UNDERFLOOR PLUMBING
❑ lam mptunder ,B&PC mrtnia ,von 203 - UNDERFLOOR MECHANICAL
0 ER'S COM
10 ECLAR TIO ata$ a 3 204 = UNDERFLOOR FRAME
9hereby affirm ad&,perm¢yof pcejmy on,of me following xchounnimer 205 - UNDERFLOOR INSULATION
❑l have and will maintain a Cenmearcofconsenuoself-insure forworker's Cumpcn- 301 — ROUGH PLUMBING
urian,as provided for by Section 3700 of the IaWr code.fm the perform.of the 302 - TUB & OR SHOWER
work for which this permil is issued.
❑I haw and will maintain Worker's Compensation Insurance.0 required by Section 3 03 - ROUGH MECHANICAL
37W of the Upon Code.for tW performancoof the work for which dsisp.it is issdmd. 304 - ROUGH ELECTRICAL
My worker's Compensation Insurance carrier and Policy number am: 305 — FRAME
Carrier. Polity No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS' 306 — HOLDOWN.S
COMPENSATION INSURANCE 307 - INSULATION
'aless) section need not he completed ifthe Permit is formic hundred dollars(gl W) 308 - SHEETROCK
T unify teat in the permmnan u,of the work m,which this permit is issued.I span am 3 09 - EXTERIOR LATH
employ any Person in any manner so as to become subject o that workeri Compensation 310 — INTERIOR LATH
Laws of California.Date
Applicant 311 - SCRATCH COAT
NOTICE TO APPLICANT:If.-Bcf making this Ccnificam of Exemption,you should 313 - ROOF NAIL
became subject to the Workeri Compensation provisions of the LaWr Cole,you must
] � rormwimcomply with such Prnviamaaanni.prmilmm�Waamrerevakm. 501 - FINAL ELECTRICAL ENERGY
Z=
CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
1 hcrchy,affirm that dome is a construction lending agency for the Performance of
Z> Nc work for which this permit is issued(Sec.1097,Civ.C.) 503 - FINAL MECHANICAL ENERG
1fender's Name
Lender's Aeem.. 504 - FINAL BUILDING ENERGY
;J O 1 certify that 1 have tend this applieudion and aam that the anow information is 505 - FINAL ELECTRICAL
comet 1 agree to comply with all city and county ordinances and state laws mlming to 506 - GAS TEST
V building o0nsmanion,and hereby aothorimrcpromplativesOffits City toenter upon do,
gIN PLUMB G
'hve
o -mentioned property for impaction purposes.
L LS= (We)agree to save,indemnify and keep harmless the City of Cupertino against 0 8 FI Ice
rA liabilities,judgmens.costa entl expenses which rosy in any way acerae agmina said City 5
JZ incmrscquermeafdregmming mflhis it.
^ APPLI NT UNDERSTAN S A D WILL COMPLY ALL ON�P INT Issued b
URjRE�GULA NS. fI Y'5 TNG Date
��3 Re-roofs 514 NAL PUBLIC WORKS
Smgnamrc ofwppbcaHAZARDO Date p2 - ROOF PLYWOOD NAIL
HAZARDOUS MATERIALS DISCLOSURE Type of R b
Will the applicant Of future building occupant marc or handle hanNuus material 3 - ROOF BATTENS
= defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety 6 p 4 - ROOF IN-PROGRESS f
.pvrs 255J2(a)? /. All roofs shall be Inspectedprior to any rooting material being installed.
Will mea licant or future Wdain aro ant use a If a roof is installed without first obtaining an inspection,I agree to remove
pP g p equipment or devices which g P
emit hazardous air contaminants as derned by the Bay Arca Air Quality Management all new materials for inspection.
District?
Yca ANo
I haw mad me mount materials requirements under Chapter 695 of the Califor.
ria Heralds&Safety Code,Sections 25505.255]3 and 255.)4.1 undersand that if thc Wilding
docs not c rremly hoc. nand that it- my rcsionobility m nod ly the aceupanl of me
rcyuire swhichm of br issuance ora Ccrtificam of c ry.
2 0 Signature of Applicant Date
nor or authodsd agent D,m All roof coverings to be Class "B" or better
1