03050093 OF
CI
BUILLDI c DIVISION
PERMIT CONTRACTOR INFORMATION
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BUILDING ADDRESS: WAYNE GONG PERMIT NO.03050093 30050093
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'S NAME: PERMIT ISS E DATE05/ 2003
YNE GOING,
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT0ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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18 O LICENSED CONTRACTOR'S DECLARATION
IOu C I ion 7 affirm N.s T am Ranee under Provision of Chapter 9(commencing is Job DeseriptioU
L� wif.IIfD nm110)afDivisionJaf the Busircsa and Profession Code.andmyliccnse is
v y Lifullocla and effect
>qz Lieencclssa Lic.g TI-BATHRM UPGRADE '
Dam Camnmor SEP 3 9 2003
}� ARCHMCTS DECLARATION
f W< 1 understand my plans shall he used as public record
?03 LicensedPrufessumal BUILDING
OWNER-BUILDER DECLARATION
7 I hereby amort that I am exempt from He Cummins's License law far the
2
DC) following mason.(Seetiun 7(31.5.Business and Profession Code:Any city or county
IS K which requires a permit to comet alter.impmve,demolish,or repair any structure
_Zto prior in its issuance.also requires the applicant for such Permit to file a signed statement
that he is licensed pursoanita the provision of the Common's License Law(Chapter 9 Sq.Ft. Floor Area $"W8a6ion
n G (Co..
wiH Smion]OW)af DivuionJ of arc Businev and Profession Codc)ur ::JJ VV l/
Q $ that he u exempt therefrom and He basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the appliCML to a civil Penalty of 3�$1$�31BT9 [0 0 Occupancy
not mom than live hundred dollars(1500). Pane Y Type
❑I.as owner of the pmprny,mmy employes with wags uthe'v sole compensation,
will do the work.and He structure is not intended moffctrd Waste(Sec.7W.Business UNDF Jd IHSpeCtlOns
and Professions Code,:The Contractors Liana law does not apply m an owner of
propeny whobuild orimproses thereon,andwho doessuch wart himselfor Wough his 102 — PIERS
own employee,pmvided Nat such improvements are not intended oroRered forage.If, 103 — UFER
however,Ne building or improvement is sold within one year of completion.the owner-
buildr will have the burden of proving H.,he,did not Huila or improve for purport of 104 — REBAR
sale.).
❑Las Cons"
or Property,am allusively emmacling with licensed conmemrs 10 105 - ANCHOR BOLTS
constom".pmjem e,.7 ,B.irtr and Pmfasians Coee:)nC Coutrrctars u. 106 — SEWER & WATER
ccne law data mol cep man awrrer of property who build sir improves Hereon.Nd
who con s bpm acantnnorts)liaasedpursanl to rte Canuanors' 202 — UNDERFLOOR PLUMBING
Lijne 203 - UNDERFLOOR MECHANICAL
0.Y lam a tun F ,Bd:PCIw N�is�C�as-o3n 204 - UNDERFLOOR FRAME
r\ eER'SCOMPENSATIONDEC 205 - UNDERFLOOR INSULATION
Lheaby a der penally or perjary as or the followNg deAantion: 301 — ROUGH PLUMBING
❑Ihave and will maintain aCutifiam ofConent m self-inum for Wmkerscompeo- 302 — TUB & OR SHOWER
sation,as provided for by Section 37M of He labor Cade,for the performance of the 303 - ROUGH MECHANICAL
01havc for aichHlapaimvaissae. 304 - ROUGH ELECTRICAL
❑I have and will maintain Workers Compensation words
fin Insurance.h rnyvired by Sss u d.
My Wcth,es Co Code,forNapatfarmaneeaf He wart fmothraHis permit is issued. 305 — FRAME
My workers Compensation lnsonnce conic Poli Policy number are: 306 — HOLDOWNS
Cartier. CERTIFlCATE OF EXFMPTION FROM WORKERS307 — INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
(Thuscnionnecdn becunplaudlithe Permit isname, undaddollars(SIM) 309 - EXTERIOR LATH
I ccmfy Na n e Ca of Ne work for which this permit is issued.I Nall not 310 - INTERIOR LATH
employs. personi an crso.W o es.bjc)nie ttWorkeriCompcnmlon 311 — SCRATCH COAT
wa ore domia. 313 - ROOF NAIL
E A f,aflcrmakingW1CcnificateorEmontion,youshould 501 - FINAL ELECTRICAL ENERGY
become sobject kcra Imor uuon provision of the labra Code,you mug
,J zO foMwith comply such Provision or this Permit shall Wdames mvolme. 502 — FINAL PLUMBING ENERGY
? y CONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL ENERGY
'r4 1hereby a1 .0-1them isaeoel—tionlending agency for due pm(.....f
G' > the wor504 - FINAL BUILDING ENERGY
work Tor which His perms Is good(Sec.309],Civ.C.)
d 0 IandcrsNamc 505 - FINAL ELECTRICAL
7z LmdersAdd.. 506 - GAS TEST
U O I ccnffy that 1 have mad this application and sum that the above information u -
(r,Pcorrect 1 agree to comply with ah city and county ordinances and auto laws relating to 507 — FINAL PLUMBING
OU building construction.and hereby moorim mpmsenutives of this city to corer upon in FIN MECH CAL
r shave-menti ncd pmPa for inpenian purposes
I gy (we)agra to save,t mnify and keep,harmless the City of Cupertino against 0 9 FI )
rn Iiabilities,jad menu,Cosa and nsa which mvy in any way attnc agvnst saidcity 5 NG
U incanseque fNcgmmingof ispermit Issued 5
^ APPLICA DERSTAND NO WILL COMPLY WITH ALL NON-POINT y; CVG
Dale
SOURCE EG ONS.
S 63 Re-roofs
S' lure ofA tan onmcm" am
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
will the p licamum future building occupant gore or handle hvardous material
&rind by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety -
Section zssJz(a)?
Dy. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or furore building occupant use equipment or denies which
nMNa If a roof is installed without first obtaining P g an inspection,I agree to remove
emit hazardous air contaminants as dcrined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes ;WNo
I harc aJ the hva smaa:rials nquimoenu under Chapter 6.95 ofthe Califon
nu Ha1N& Code,Sec J5505.255JJand7S5Jd.1 un tlNazifde Wilding
docs trot c t a ¢n t Naz it u my msponiltilitY m tto the attupant of the
myuim n w x mprio"missa.rmeohcenin Har eppanay. Signature of Applicant Date
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owner or agars D,m All roof coverings to be Class"B"or better