03020096 CITY OF CUPERTINO
BUILDING DIVISION PERMIT COqNTRACTOR INFORMATION
BUILDING ADDRESS: CUPERTINO CONSTRUCTION INCPERMIT ND.03020096
R'SNAME: 10079 SAICH WAY PERMIT ISSUE DAM
O
PHONE: (408) 253-9000 SANITARY NO. CONTROL NO.
ARCHmICTIENCINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
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top LICENSED CONTRACTOR'S DECLARATION Job Description
0UF I hereby affirm that I am licensed under provisions of Chapter 9(commencing
p
with Section 7")of Division 3cu NC Basin.aM Pmfcssione Code,end my livevc is
nefmlu anderret. 7-Sl�U9r� NEW 2-STORY 5 . 33 Q )
Li C " LicJ
p -^ —c9 ^�°'yyr� LIVING SPACE 33 G 664 S . FT
.-tj N CNI'IECI'S gPCI:ARATI
FmI untersmad my plamsMll he used as public records
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'0, Licca dPrnfesxianel DEC 8 2004
S OWNER-BUILDER DECLARATION
<bi I hereby alRrm that I am exempt from the C.nu.aer'e Licensee Law for,he
p O following mason.(Secdun 70315.Business and Po esxiom Code:Any city or county
<m which realities a permit to eonsuua,alter,improve,demolish,m mpair any sdmcwm
°iO prior o its issuance.also mania the applicant for such permit m flea Og.edsdaemen,
that he is licensed pursuant u the pmvl3l.R oldie Comrxtur's License Liw(Chapter 9 Sq. Ft. Floor Ar Valuation
Zip (commencing with Section 70(0)of Division J of the B usineu and Psarnsoms Cartel or
that he is escmpt therefrom end me basis for the alleged exemption.Any violation of $390817
Section 7033.5 by any applicant fora pcmtit subjects the applicant 1.a civil penaly of APN Number Occupancy Type
not mom man f hundred dollars(5500). -—--
01,as owner of the property.or my employee,with wages As their And compensation, 35701017 . 00
will du the work,and demotions is nut intended or offered for sale(Sec.7044,Dalian.
and Pmreesi.na Code:The Contractor's License Law docs net apply to an owner of Required Inspections
pmpeny who builds.,improves thereon,and whudecs such work himself or da ough his
ownemployees.provided mats.ch improvements amnotmtended.,offered(.nils.if. 101 — FOUNDATION
however,am building Or improvement is sold within one year of completion.the nwno-
builder will have the burden of poring that he did not Wild o,improve for latitude of 102 - PIERS
"It.)' 103 - UFER
❑ I,as owner of the pmpeny am exclusively contracting with licensed conuanors to - -
<nconstruct the project(Sec.7044.Business and Professions C.de:)The Convacmr'3 Li 104 - REBAR
ue law don not apply a.A.owner of pmpey who Wilds or improve thcmon.and. 105 — ANCHOR BOLTS
who contracts for such projects with a con"cloo5d licensed pursuant to the Conmacmr's
LicenteLa . 106 - SEWER Se WATER
❑ I am extra pd under Sec. ,B&P C for this mvnn 202 = UNDERFLOOR PLUMBING
Data- 203 - UNDERFLOOR MECHANICAL
WORKER'S COMPENSATION DECLARATION
1herebyaffirm under Penalty ofp utyoncofthemu"wing declarations: 204 - UNDERFLOOR FRAME
❑ Inane a.d win mammi..cemBeam.reonaen,d.eelrna.m roti w.ner•.cmnpe.. 205 - UNDERFLOOR INSULATION
Satin,as pmvlded for by Section 77W of the LAW,code,f.,the perf.rmance of the 3 01 - ROUGH . PLUMBING
work ter which this ptmLLls issued' 302 - TUB & OR SHOWER
Fl nave and will maintain Wmkers Compensadi.n Insurance,ss mquimd by Sodium
37M of the labor code,for the performance of the work for which this permil is issued. 303 - ROUGH MECHANICAL
My Worker's Cn scion lnsunnce camm,and Policysbcr art:
P ¢p� �{� �[[�p 304 - ROUGH ELECTRICAL
c,rri,:�PA75-++ EE7gFM Polieydi9a/J�1ERS L_ 305 - FRAME
C IN�' AT`E'OF Pf10NF 61 WORKERS'
COMPENSATION INSURANCE 306 - HOLDOWNS
(This action need not W completed if the permit is for one hundred delta.(I lisp 307 - INSULATION
or Ices.)
I certify that in he perbmnance of the work ter which this Permit is issucd.I shall n., 3 08 — SHEETROCK
employ any person in any manner se,as In become suhJCCL to the Workers'Compensation 309 — EXTERIOR LATH
Laws of California.Dan
Applicant 310 - INTERIOR LATH
NOTICE TO APPLICANT:IL after making this CCi ifcaii of Exemption,You should 311 - SCRATCH COAT
become subject to the Worker's Compensation provisions of the La ver Cade,you must
�'Z forthwith comply with such provisions or this permit shall W deemed revoked. 313 — ROOF NAIL
zO CONSTRUCTION LENDING AGENCY 501 - FINAL ELECTRICAL ENERGY
I hereby affirm that there is a construction lending agency for the performance of 502 - FINAL PLUMBING ENERGY
> the work for which this permit is issued(Sec.3l197,Ci,C.7 503 - FINAL MECHANICAL ENERGY
'y Lcndcr's AW
Dz Lnder'sAddress 504 - FINAL BUILDING ENERGY
J O 1 eenify that 1 have read his application and aim that the above inrom Ado.i. 505 — FINAL ELECTRICAL
erammd.I agree to comply with all Nal and coon 1,ordinances and start laws rclaling do
�UWilding convection,and hereby aurrorin mpresentadirn on or this city do ender upthe - GAS TEST
W above mentioned properly for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against %7FI
,� liabilities,judgments.costs and expenses which may in any way accrue against.said City..l z in his Nmail.
APPLICANTUNDERSTANDSITHcof the timing of tAND WILL COMPLY WALL NON-POINT Issued by: Date
SOURC ' ULATIONS. / NAL PLANNING
J —� — ^ Re-roofs
9:warc of Applicanvc.ndmed Date 5 4 - INAL PUBLIC WORKS
HAZAR US MATERIALS DISCLOSURE Type ofRo�e�2 - ROOF PLYWOOD NAIL
Will the applicant or future building occupant store or handle hvardoos mammal
n defined by he Cupenin r Municipal Code.chapter 9.12,and he Health and safety 603 - ROOF BATTENS
Section 255321.)? All roofs sl�p"e insl;RFfe�priTlp pipiOreginRgaterial being installed.
' ❑Ye, b"dr
1 • Will he applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air conuminanu as defined by the Bay Area Air Quality Managcmcnt all new materials for inspection.
D'suic,?
❑YCS
Ihave mad thc1 eta tnsmaterialsmqulmmenuunder Chapter6.95orthc Califon
nice Health&Safety Code,Sections 25505.25533 ave 2553.1.MrsterM muifdhe Wilding
does not curmady have a tech^mat it is my resfameanlity m 'fy the axupand of the
mqui nuwhichmusibcmedprriioo�rtoissuanccof.Cenifca¢ pNcy Signature of Applicant Date
M
owner.,a.m.medage Dan All roof coverings to be Class "B" or betterCA