03090099 CITY OF CUPERTINO tr r�-.�+" + 3a #.at' �.' ''• :
BUILDING DIVISION PERMIT NONTRACTOR INFORNINTIQN
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BUILDING ADDRESS: PERMR NO0 3 0 9 0 0 9 9
41c; RPM V CREEK PT
R'S NAME: PERMIT ISSUE DATE
2003
VIA
NE: SANITARY NO, CONTROL NO,
ARC HITECTIENGINEER: BUILDING PERM R INFO
BLDG ELECT PLUMB MECH
o t� o
ioo
LICENSED CONTRd under previsions
or CON
I�z I wrcby affirm that I am Itttnud undo provisions rf Chapter Y(commencing IOU DOSCflpI100
s< with Section 7000).f Division 3 of the Business and Professions Code.and my licensee
to mnfoma.ntlerrwL FIRE DAMAGE REPAIR (300 SQ. FT )
vii Z License Class Lic.N
J Dale Contractor
ARCHITECTS DECLARATION �/[%��sp,' /9p q
I I underuand my Plato shell bo used as public record /'//"
6 fY9/1 IµVKp
Sfpoo0 Licensed Pmfeuionel
a OWNER-BUILDER DECLARATION
COOhereby affirm an 1 1. exempt from Iw Contractor's :Any Law for the '
00 following reason.(Scedun]WLS,cosines and Pmfcuina Cale:Any oily Or county ✓/
$ which requires a Permit to cnnshect,'her,borrow.demolish,or¢pair any structure Ly
0
prior o its issuance,also sequins the applicant for such permit to Bic a signed statement
C that he is licensedpursuanttntheprovisionsoftheContractor'sLicenseLaw(Chapter9 Sq. Ft. Floor Area on
` $ (commencing with Section 7")of Division 3 ofthe Business and Pmfeasions Code)ur
Chet he u exempt tMm rcfroand the basis far ther alleged exemptlat.Any violation of 34248021 . 00
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of _
nut mem than five hundred dollars(S500). - - - - - _APN Number
❑1.as owner of Me property,tar my cmployas with wagas u theinole campenutlOn,
will Me the work,and Ne swcturt I+not intended or onered for sale(Sec.7044,Busidass
and Frofassiom Cock:The Cmaracme.Licence law dote not apply to an owner of 10 2 - PIERS d Inspections
property who builds or improves themon,and who does such work himself orthrough his
own employees,provided that such improvements are not intended oro@red for sale.If, 103 — UFER
however,the building or Improvement Is sold within one year of completion,Ne owner,
builder will hue the burden of proving Nat w did not build or improve far purpose of 104 - REBAR
asle')' 105 - ANCHOR BOLTS
❑1.as owner of the property,am exclusively contracting with licensed convectors to
constmet the project(Sec.7044,Business and Paramours Code:)The Contractor's Li- 106 — SEWER & WATER
cease law docs not apply an an owner of properly who wilds or improves lhemon.ud, 2O2 — UNDERFLOOR PLUMBING
who contracts for such projects with a contractor(s)licensed pursuant to the CommercM1
License law. 203 - UNDERFLOOR MECHANICAL
Qlame amps der Sec. ,B B P C f this moon
r' 40 04L ' o+tel 204 - UNDERFLOOR FRAME
WORKER'S Oh , SATIONDECLARA gGpl 205 - UNDERFLOOR INSULATION
Iwrtby eRrm under penalty of perjury one of Men follow✓ing dc<lantions: 301 — ROUGH PLUMBING
I have and will maintains C.nlOcamaf Consent to self-insure forlMaker's COmpcn. 302 — TUB & OR SHOWER
urian,
as provided for by Section 3700 of the law,Code.for the performance of the - 303 — "ROUGH-MECHANICAL
mit
work far which this perI.island. 304 - ROUGH ELECTRICAL
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of Me labor Code,(or Ne performance of Ne work for which this Perm it is Issued. 305 — FRAME
My Workers Compensation Insurance carrier and Policy number am: 306 — HOLDOWNS
Cartier. Polity No.:
CERTIFICATE OF E%EMMON FROM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
aces.)
('ITeanclace need notes completed if Me,Permit is for one hundred dflizo,SIM) 309 - EXTERIOR LATH
- 310 - INTERIOR LATH
employ eenify ny i r Ne performance of the work for which Nis permit is issaA,I+hall not
L.ws.any Pr..is, any manner mastu become subject to the Workeri Campcasanon 311 — SCRATCH COAT
Laws of CBhfalniO.Data
Applicant313 - ROOF NAIL
NOTICE TO APPLICANT:IL after making this Crnincau of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
became subject to the Workers Comperwtion previsions of the labor Code,you mute
� z forthwith comply with each Provisions or this Permit hall w doomed invoked. 502 — FINAL PLUMBING ENERGY
z CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
I hereby affirm that there its conurvctinn lending agency for the Performance of5
Undoes Nam. 04 - FINAL BUILDING ENERGY
z urwhich thup mit isiurc0(Sw097
.3 .Civ.C.) 505 - FINAL ELECTRICAL
it G Lenders
� Z Lnder'sAtldmas 506 - 'GAS TEST
p IceNfyMet 1them readthis ppiietaiotand sUlm Met theseem tnformntunis 507 - FINAL PLUMBING
y COMCL I aip ee to comply with all city and county ordinances and state laws relating to�" wildingconswction,and hereby authorim mpreamulivesof this city tocrac"prt the — FIN MEC IC4Date
W shove-mcnilaned p trany for impaction purposes.
4 LL (We)agree to ties,indemnify and keep harmleu Ne City of Cupertino ageiasI V09 F Iliebilitics.judgmenu,custs and expenses which may in any way accrue ageinn saidCity NG.3Z to conrquened of Im lootingof this permit.APPLICANT UNDERSTANDS A L COMPLY WITH ALL NON-POINT Issued by: C W
rREG _G _ Re-roofsp H ZARDOUS MATERIALS DISCLOSURE DauType of Roof
e applicant tar to, wilding Occupant store or handle hnardous maurial
the Cupertino Municipal,Code,Chapter 9.12,and the Health and Safety
.zss3x°7 All roofs shall be ins ected rlor to an roofin material bein+ ,n p p y g g installed.
e applicant of future building Occupant UK equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
m air Contaminants as donned by the Bay Arca Air Quality Management all new materials for inspection.
❑Yea
1 have iced the hnankno materials requirements under Chapter6.95 onhe Califon
nia Health dr Safety Coda,Scerr as 25505,25533 and 25534.1 unwersund thaldift wilding
Joos not currently haw a unam.thea spo
it is my remy to lhilitnobly the Occupant of the
myyi mentswhwhmnnwin wt Basleofoaca ISignatureofApplicant Date /
n.ronuthorizeJ sant Data All roof coverings to be Class "B"or better