02100153 CITY OF CUPERTINO =BUILDING DIVISION DIVISION PERMIT COfT , ' 2,0RhINFORMATION S%
nu14D0Y62P!9H;S10HANSEN DR. ROCKWOOD CONSTRUCTION COR I;FRMI'fN021O0153
ME111DOON GHIASSI 248 BELDEN DR. APPLR"TIPl5sJ23STY2002
ONE: (408) 227-7999 SANITARY NO. / CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB METH
OKZ
� 00 LICENSED CONTRACTOR'S DECLARATION hhp �ir�t
rI hereby affirm that I am licensed antler provisions of Chapter 9(commencing REVISION- -IN H18U S Se V 5 n ONLY
w with Section 7lakpnl Division 3 of the Businessand Professions Coda,and my license is
infull forward rarot. ORIG. 402040114 , NO NEW PERMIT ISSUED
qZ Licnnse Clas @�
Date CContonn� ractor
ARCHITECTS DECLARATION
�aSy�-4 lunderstand myplans shall Mused aspublic mcnrds
W C,
=LLO Licenwd P...Osinnal ��+
OWNER-BUILIS
DECLARATION S
W il 1 hereby affirm that 1 am exempt from the Contractors License law for the
tFOO following Mason.Section 7131.5,Business and Professions Come:Any city or county
$� which requires a permit to construct.alter.improve,demolish,or repair any structure $140000
prior m its issuance,also requires the applicant for such permit m file a signed showman_�< that he is licensed pursuant m the provisions of the Contractors License Law(ChaperY Sy. Ft. Floor Area Valuation
jy O (commencing with Section Too)of Division 3 n(the Business and Professions Code)nr
$ Nat he is exempt therefrom and the hasis for the alleged exemption.Any violation of 3 7537064 . 00
Section 7131.5 by any applicant for a permit subjects the applicant o a civil penalty of APN Number Occupancy Type
not mom than five hundred dollars($300). 101 - FOUNDATION p y Yp
0 I,as owner of throes ss
e ppany,or my employees with wagtheir mile compensation,
will do me work,and Ne structure is not intended or offered for sale(Sec.7044.Business 102 —
PIERS I
and Professions Code:The Contractors License Law Nes not apply to an owner of 103 — UFER Required Inspections
property who builds or improves thereon,and who does such work himself or through his
Own employees,provided that such improve cots we not intended or offered for sale.If, 104 — REBAR
however,be building or improvement is sold within one year of completion,the owner- 1OS — ANCHOR BOLTS
builder will have the burden of proving Nat he did not Wild or improve for purpose of
"It.). 106 - SEWER & WATER
D1.as Owner of the propi am exclusively contracting with licensed contractors to 202 - UNDERFLOOR PLUMBING
construct the project(Sec.7044,Business and Prolusions Coi The Contractors Li.
crow law does not apply to an owner of property who builds or improves themon,and 203 - UNDERFLOOR MECHANICAL
Lraenmtracts for such projects with a arntractorEd licensed pursuant the Contractors 204 — UNDERFLOOR FRAME
❑limatemptunder Sea ,B&PCfonhiaremn 205 - UNDERFLOOR INSULATION
Iher IDare 301 - ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION 302 — TUB & OR SHOWER
I hereby affirm under penalty of perjury one of the following declarations: 3O3 — ROUGH MECHANICAL
I have and will maintain a Certificate of Consent to sff-inaumforWorker'sCompen-
on,as provided for by section 371 of the labor Code.for the performance of the 3 04 - ROUGH ELECTRICAL
k for which this permit is issued. 305 — FRAME
1 have and will maintain Worker's Compensation Insurance,as required by Section 3 06 — HOLDOWN.S•0 ofthe Labor CnJe,for the performance of Ne work for which this permit is issued.
Workers Compensation lnsumnce,carierand Policy number am: 307 - INSULATION
Carrier: Policy No, 308 - SHEETROCK
CERTIFICATECOMPENSATIfON INSURANCETION FROM 309
309 — EXTERIOR LATH
Mis union need not he completed if the permit is(Drone hundred dollars DROB 310 - INTERIOR LATH
m less.) 311 - SCRATCH COAT
1 coolly that in the performance of the work for which this pmmit is issued,1 shall not 313 - ROOF NAI L
employ any Khoo in any manner so subject as to become subjeco the Workers'Compensation
Laws of California.Date 501 - FINAL ELECTRICAL ENERGY
Applicant
NOTICE TO APPLICANE If,after making this Ccrificam of Exemption,you should 502 - FINAL PLUMBING ENERGY
Become subject o the Worker's Compensation provrlons of the Lalwr Come,you must 503 - FINAL MECHANICAL ENERGY
O Z fcomply with comwith such provisions",this permit shall be deemed rcwkxd.
CONSTRUCTION LENDING AGENCY 504 - FINAL BUILDING ENERGY
[. .N. Ihemby affirm Nat there is a constomoon lending agency for the pedi"manccuf 505 - FINAL ELECTRICAL
C > the work for which this permit is issued(Sec.3097.Co.C.) 506 - GAS TEST
W Q lsndeex Name
Z f<mders Address 507 - FINAL PLUMBING
U O I certify that 1 have mad this application and slam Nat the above inkonation is 508 — FINAL MECHANICAL
Ip f-' correct.I agree tocomply with all city and county onfinface.%and state hossichating to 5 AL GRADE
Q building construction,and hembyauthorw represematiwaofthiscitymemcr upm the
}' W above mentioned property for inspection purposes. 5 ;04F G(We)agree to save,indemnify and keep harmless the City of Cupertino againstN liabilities.judgments,costsand expenses which may in any wayaceroeagainstsaidCity 5 L WORKS
fJ 7 in consequence of Ne granting of this perm it.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date C
SOURCE RCGULNNONS.
Re-roofs
Signamrc of ApplicaAZARDO Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or(Muni building sec haps store or handle Heal
material
as de,Second
by the 32(a)?nu Municipal Code.Chapter 9.12,and Nc Health and Safety
bee.section zs53z(e)9 All roofs shall be,ins ected prior to an roofing material beim Installed.
El Yes E]No P P Y g g
Will the applicant or future building occupant use equiparent ordevices which If a roof is installed without first obtaining an inspection,I agree to remove
can
hauardom air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
District!
Dyes ElNo
1 have read the Immudous materials m immments under Chapter 6.95 of the Califor-
"in IleaWt As Sulcly Cush.Sections 25515.25533 and 25534 1 understand that if the hui lding
does not currently haw a mnam.than it is my responsibility to nodfy the occup d,of Ne
requirements which mum the met prior tot luance of a Certificate of Occupancy. Signature of Applicant Date
Owner oraaorimmlagent Date All roof coverings to be Class "B" or better