03090009 CITY OF CUPEWI'INO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION ,"
BUILDING ADDRESS: A V CONSTRUCTION PERMIT"03090009
"vRES NAME: 1145 W IOWA AVE PERMIT ISSUE DATE
I(1 ONE: (408) 245-6707 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
seta LICENSED CONTRACTOR'S DECLARATI 1r G� O O O
�u F I thereby affirm that 1 am licensed under provisions orChapl�iry(commencing Job Description
<n with Section 70R)of Division 3 ofthe Business and Professions Code,an ylic=m=is
iq? infullClassome err=eL REVISIONS-BEAM REPAIR
Ucenx Class Llc.x
s t-m Date CunTrxctor
j ARCHITECTS DECLARATION
31 u 1 understand my plans shall w seed u public ecnNs
O� Licensed Professional
OWNER-BUILDER DECLARATION C\
a P 1 hereby affirm That I am exempt from lc Canuaaors LicenseLaw for IM O
00 following moon.(Section 7131.5,Business and Prefemiom Code:Any city car county
COO
mwhich requires a Permit to construct,alcor.improve,demolish,or repair any structure
prior In its issuance.also requires the applicant for such permit to file a signet ma¢mcnt
_y< that he is licensed pursuanuo the provisions of the Conuacsor's License Law(Chapter 9 _ Sq.R. Floor Area Valuation
21-0 (commencing with Section 7")of Division 3 of the Business and Pfofessione Core)or
that he Is exempt therefrom and The bssis for the alleged exemption.Any violation of 3571 0 \�
Section 7031.5 by any applicant far a pemnitsubjccid the applicant to a civil penalty of APN Number OCCU ane T e
not more Than five hundred sonars lS500). - - - - - ..__ .. P Y Yp_ -
1,as owner of the property,or my employees with wages m their sole compensation.
will do The work.and Ne structure is not intended or offered for sale(Sec.7n.Business 1 1 - FO e�j d Inspections
and Professions Code:The Connector's License Law does not apply to an owner of
property who builds or improver thereon,and who dace such work himselfor through his 102 — PIERS
awn employee,provided Nat such improvements arc not intended or offered for role.If. 103 — UFER
how weq The building or improvement is sold within one year of completion,Ne owner
builder will have the burden of proving that he did not wild or improve for purpose of 104 - REBAR
Y )
.as owner of the propcny,am exclusively convecting with licensed comnscinrs To 10 5 - ANCHOR BOL
onstmn the pmjen(sec.nun,Business and Professions Code:)no Contractor's Li. 106 - .SEWER & WATE
come Taw does not apply w an owner of pronny who wilds or improve Orman.and
who contracts her such Projects with a conmcwr(s)leaned pursuant to the Conmcora' 202 - UNDERFLOOR PL ING
01me Law. 203 - UNDERFLOOR MEC ICAL
❑ Iemexempt under
tSee. (� �s —f ,B&rP']Cfor this n 204 - UNDERFLOOR FRAME
Itiissaal ' I./ I'�I'I Y1 \t Dao —\ O
IVWORKERS COMPENSATION OEC�§g�gTF)ppN 205 - UNDERFLOOR INSULAT N
I hereby affirm under penny of perjury,one of t NKe llawing daWrItiOm: 301 - ROUGH PLUMBING
Thaw and will maintain a Certificate of Consent w acf-insum for worker's compere 302 — TUB & OR SHOWER
cation,as provided for by Section 3]Bo of the labor Cede.for the perfmmansc of the 3 03 - ROUGH MECHANICAL work for which This pcnnit a issued.
❑1 have and will maimain Workers Compensation Insurance,as required by Section 3 04 - ROUGH ELECTRICAL
37M of the later Code.for On arfarm.ncc of lM work t'nr which this Permit is issued. 305 - FRAME
My workers compensation Instant carrier and Policy nmxr am: 306 - HOEDOWNS
Cartier: CERTIFICATE OF MEMPr10NYFROM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
This section need notwcompleted if the permit is for one hundred dollars 309 - EXTERIOR LATH
or less)
I«nify Nur in me froformanc of The work her which miss p=limit is :mea.I than not 3 10 - INTER I OR LATH
employ any person in any manner In as in hccomc subject to tw Work.,SCcon,ruation 311 - SCRATCH COAT .
Laws ofC remiss.am 313 - ROOF NAIL
App icant Ir —
Na CTOAPPLICANT orkerallcrmakingNisCili.ramtheLabrors.yenoa, 501 FINAL ELECTRICAL ENERGY
hjop w the Worker Comleor this provisions of Tde laver Code.you muse
Z O rot thenmpiywith such prnvicmmnrmiap miunauwdeemeemvnt=d. 502 - FINAL PLUMBING ENERGY
zy
CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
IwrcOY which this
On(there iised(Secunn lending agency for she performance of 504 - FINAL BUILDING ENERGY
]'
the work for which Thu permit is issued(Sec,lfH],Civ.C.)
i p
Under i r' Address Name 505 - FINAL ELECTRICAL
Z) z Lc
j O 1 certify that 1 have rod this.pollution and sure In.,the above information is 506 — GAS TEST
yFcorrect.I agree to comply with all city and county ordinances and State Laws relating to 507 - FINAL PLUMBING
'v building consuaction.and hereby awborirs trPesenutiwa of This City w enter upon The 4INPAMECTNG-
APPLICANT
AL
U above mentioned property for inspeenon purposes.
a. (We)agree m cove,indemnify and kccp harmless the City of Cupcnin0 against 0 9
jW) liabilities.judgment,costs and talent which may in any way accrue against slid City 5
in consequence of the granting of this permit UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued bSOU CE REGULATIONS. Y5 ORKS Date
x(310
n tors ofApplicanuCon nxwf Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will The applicant or fuwrs willing ncupam there or Mndlc hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
c,Section 15532(a)?
❑Yn 11i'Nu All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building uecupn use equipment If a roof is installed without first obtaining an inspection,I agree to remove
yes proem ar team which g p
Dmitict? s air contaminants as JcfncJ by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes }�Nu
1 hate mad the hmaNres maedals rsyuimmcnts under Chapter 695 of Bre Califon
nicer or, aSafetyCDM, it is a.moundn,iflM wilting
Jras not cuncmly have a wnanrI Nat itis"u reapansiM1ility w nndly the r pent the
wquim u which must w t p' r w issuance of s Centric.¢of Occupan
Signature of APA- pplicant Date
Dv .1 aathmimdage., he All roof coverings to be Class "B"or better