03070024CITY OF CUPER'fINO
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BUILDING DIVISION PERMIT
.�CON'TRACTOR,
AIT
NFMAT
IORON
Yrx. , avv ,O
BUILDING ADDRESS:
Et" Wr1Iv[ESM2Ap RD
PERMIT NO03070024
R'S NAME:
iE�E:
PERMITMUEDATE
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
1 hereby 1 licensed Chzpmr of
Job Description
afrrm that am undo pnrvisions of commcncing
with Section) 1 fDiviaionJof the Business and Pr�(euium Code, end mylicenm is
in bull tome an rf n'
of old I r oj3��a
TI--STAIRS/UPGRADE
RAILS
Da contra
°—ONTRACTOR:HILLHOUSE
CONSTRU
ARCHITECTS DELLAION 2�
ALE'®
1 understand my plans shall M used asp a records
OCT 2 7 2003
Licensed Professional
OWNER -BUILDER DECLARATION
1 fetch, affirm thin 1 am exempt boom the Contractor's License Law for the
following mason. (Section 7(*I.5, Business and Professions Code: Any city or county
which requires a penoit m comaruct, alcor improve, demolish or repair any structure
RHILDING
prior to its issuance. also requires the applicant for such permit to file a signed statement
that he isran=vapursuant mthe provisions ofthe ComoneorxLimm�eLaw (Chapter 9
Sq. Ft. Floor Area Valu$tivt 000
(commencing with Section 700)) of Division J of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7071.5 by any applicant for a permit subjects the applicant o a civil penalty of
31A�Dl9iD1$t�e100
Occupancy Type
not mothan fi hundred dollars (2500
re ve ).
0 I, as owner of the property, Or my employees with wages as IMG sole compenution,
will do the work, and the swaum is not intended or offered for sale (Sec. 7044. Business
and Professions Code: The Contractor's License Law docs not apply in an owner of
eTuir d Inspections
propenywho builds or imprnvsa from o rand who dmisucn work himself or through hisON
101
- FOUNDA
own employees, provided thatsoch improvements ammoinlended oroffemd formic, If,
102
— PIERS
however. the building or improvement is sold within one year of completion, the owner -
builder. will have the burden of proving that Ile did not hili to or improve for purpose of
103
— UFER
tale).
104
- REBAR
1, as Owner of the property, am exclusively contracting with licensed Contractors to
construct the project (See.7Bna. Business and Profusions Code:) The Contracmri Li
105
— ANCHOR BOLTS
mnae Law does not apply to an owner of property who builds or improves thereon,and
106
— SEWER WATER
who contracts for such projects with a comractor(s) licensed pursuant todm Contractor's
&
LibeaaeLaw.
0 l son exempt under See. . B h P C for this reason
202
-
- UNDERFLOOR PLUMBING
at Date
203
204
— UNDERFLOOR MECHANICAL
— UNDERFLOOR FRAME
WORKER 'SCOMPENSATION DECLARATION
I hereby affirm under penalty of perjury rote Of [he following declarations:
205
— UNDERFLOOR INSULATION
I have and will maintain a ceNecam of Consent to selhinsum for WorkcisCompen.
301
— ROUGH PLUMBING
anon, as provided for by Section 37M of the Labor Code. for the permormom of the
3 02
— TUB & OR SHOWER
work for whim this permit is issued
❑ 1 have and will maintain Worker's Compensation Insurance, u required by Section
3 03
— ROUGH MECHANICAL
J7HoofthevtmCooe,fortheprrarmanceof0,workforwhichthixpenndisissud.
304
— ROUGH ELECTRICAL
My Worked Compensation lasuran. morns, and Polic m:
1;4—
305
305
— FRAME
Camicr. Policy
CERTIFlCATEOF J PTION FROM WORKERS'
306
— HOLDOWNS
COMPENSATION INSURANCE
307
— INSULATION
(TMs section need not M completed if tM permit is for one hundred dollars(SI00)
308
— SHEETROCK
or lass.)
1 certify mat in me performance or the work for whim this permit is booed, I shat) not
309
— EXTERIOR LATH '
employ any person in any manner so as to become subjauo the Workeri Compensation
310
— INTERIOR LATH
Laws of California. Date
Applicant
311
313
— SCRATCH COAT
— ROOF NAIL
NOTICE TO APPLICANT: If, ofmr making this Omifivam of Exemption, no should
become subject to the worker's Compensation previsions of the Labor GMC, you must
forthwith comply with such provisions or this permit shall W deemed revoked.
501
— FINAL ELECTRICAL ENERGY
CONSTRUCTION LENDING AGENCY
502
— FINAL PLUMBING ENERGY
IMreby aTom that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3197, Co, C.)
503
— FINAL MECHANICAL ENERGY
def''NacmO
Ne
504
— FINAL BUILDING ENERGY
Len
Under's a
505
— FINAL ELECTRICAL
I certify that I have rtaa this application and sate that the Show information is
builder 1agree to comply With all city and county ordinaries and slate lawsrelatinge
506 —
GAS TEST
construction, and hemhyaumon of this city toenter upnn the
prcpmscmatiscs
ahowngcboncil
aM1ovc-mentioned property for inspection purposes.
PLUMB G
(We) agree to ssve, indemnify and trop hvmlcss tM City of Cupertino against
Q $
L
liabilities, judgments. costs and eapenses which may in any way accrue against said City
41'
in consequence of the granting of his permit.
5
FONG
APPLIC NDERSTAN AND WILL COMPLY WITH ALL NON -POINT
Issued by:5
Dale
OUR E L S,. -��..
Re -roofs
si Oreo Applicontract D,'-n�
HAZARD US MATERIALS DISCLOSURE
Type of Roof
Will the applicant ser future building occupant afore or handle hao r mese mamtlol
as derined by tM Cupertino Municipal Code. Chapter 9.11. and too Health and Safety
Section 155R(ap
GYu ❑No
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment .1 devices which
If a roof is installed without first obtaining an inspection, I agree to remove
u ha
'ordons air contaminants u defined by the Bay Area Air Quality Management
net
all new materials for inspection.
0Yes [_1 No
1 have mad Inc harnmous materials requimmcnu under Chapter 6.95 of the Califor-
oiaHcalNYySafgtyCode, dont 5115.25573 and 25574.1 understood Nm irNe banding
d*.�cndnHa�ut mnanl mit is my mspomihilitY m nntily tM cecupant of the
b h, priorlgis oaccenrace incso roeapaney.Signature
of Applicant
Date
'rate
edagent
All roof coverings to be Class "B" or better