03080160 CITY OF CUPEWIPINO
BUILDING DIVISION PERMIT j1C0NTRAGT0RjjNFORMATION `
BUILDING ADDRESS: RICHARD & ELIZABETH ADLER PERMIT No 03080160
77 7?a 7T TOT T InFe QT
,R'S NAME: PERMIT ISSUE DATE
PHONE: SANITARY 0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O = Q
jos LICENSED CONTRACTORT DECLARATION
tt mp I Mreby affirm that 1 am licensed wader Provisions of Chapmr 9 enmmcncing Job Description
f<W with$cc,ion]IXg))e(Divixion]of thc Bus'�°'s and Prefcuinnx Code.antl yliansc ix
eco,
u==1f°rrii `r`� _Lie/r REVISION--IN HOUSE USE ONLY
°ai `rS`l °' NO NEW PERMIT ISSUED/ORIG. #02070065
`"ut ARCHITECTS DGpL.liRATION
C C< I undcrwnJ my plans shall W ilea a(pooic mcnras
)yU
o y
Licensed Professional
S Oat I am BUILDER m Ce C.Ou ON
00 1 hereby atLfm um 1 1. eBumpt from the Cssions Co License Law for,W
°O following mune.(SentoI 7031.5.Business and improve,
demolish.
h.or:Any city or roomy
<m which 24uirea a Permit,ouires Construct,alKc improve,h Permit
t or repair any structure
azi that hes its issuance.e,aHuntIn tcs,hovisiosofant for sucContrator,Liense Lnednammcm
-
i< thalhcisliccnuJPursuanuothcprovrxmnsafahcComrumrsLicenscLaw(ChaperY Sq.Ft. Floor Area Valuation 107 .
(mm
mencingwith Section 7")of Division 3 or the Business and Professions C°de)tar �7
$ that he is exempt ahertrom and tW basis for thc alleged exemption.Any violation of
Semon 703 1.5 by airy applicant for•Permit ubjects thc applicant in a civil penalty of
rats
.at...thatfive hundred delta.(5500). - - ' -" - ----- 3 N"gr00 ._ Occupancy Type. -_.-
❑1,as owner of aha property,or my employees with wages as their sole compensation,
will do Ne work and thc sbucmm is not intended or offered for sale(Seo.]1344,Business
and Professions Code:The ConracmYs License Law dors not apply to in owner or Required Inspections
properly,who builds or improves themon.and whodoessuchwork hinowlforthrough his 101 - FOUNDATION
ownemployers,pravidcd Notsuch imprownenuare nmimendrAaroRcred for,vle.If. lO2 - PSERS
hen ewl.the building or improvement is sold within one year of completion,Ne owner-
builder will have the burden of proving than M did no,Wild at improve for purpose or 103 - U4R
❑01. 104 — RE 4R
st a owner of the Ike.e phoce, 7(py..Business c and
cofmitiong with:)TheeCconuamnrt,o
cense a doesnotapplytoonowneofprod Profusions Code:)The Contractor's Lt. lOS - ANCHOR BOLTS.
cane Lawdoanoupplyman with
cfpropcny who Wilds or improves Commantl 106 - SEWER\& WATER
who contracts for such projects withacanuac,orts)liavctl pu.uammaha Conus<mh
Lice=1'w.
exempt 202 — UNDERF OOR PLUMBING
lam mpt under See. ,B&PCfor,hisrtuan
r Date 203 — UNDERFL OR MECHANICAL
r WORKER'SCOMPENSATION DECLARATION 204 — UNDERFLO FRAME
I hereby&freta under penalty of perjury one or the following declarvfonse 205 — UNDERFLOO INSULATION
❑I hese and will maintain a Cen;feat=°fc°nsentmmlt-Insure forworker's Compen- 301 — ROUGH PLUMBING
sa,ion,u provided for by Section 37W of the I A Wr Code,for Ne Performance of the
work for which Nis pc3 0 2 — TUB & OR SH WER
rmu is mord.
❑1 have and will maintain Worker's Compensadan lou mance,as required by Section 3 03 — ROUGH MECHAN CAL
37W of thc Uttar Code,for the performance of the work ler which this Farm i,is issued. 304 — ROUGH ELECTRIC L
My Workers Cnmpensadon Insurance carrier and Policy number am: 305 - FRAME
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS' 306 - HOLDOWNS
COMPENSATION INSURANCE 307 - INSULATION
or less.)This e°ine need trot W completed if the Permit is for on hundred nnnars IS IOM 308 — SHEETROCK
1 cenify Net in thc ormance of the mu for which this permit is issued.I shall not 309 — EXTERIOR LATH
employ any pc.o ' soymanners.As
wbec°me subjecuu the Wonc�ri Compensation 310 — INTERIOR LATH
LawshcoffnCralf D a
Appjq i `ns 311 — SCRATCH COAT
NOT TO'A PL A :If,after making this Certificate of Exemption.you shored 313 - ROOF NAIL
become subject to the Workers Compcwtion pmvisiom of the Isbm Cade,you muq
]� fanhwinenmpyw;m such pmviainararthis p mit:hauWaeemca revoked. 501 — FINAL ELECTRICAL ENERG
z= CONSTRUCTION LENDING AGENCY 502 — FINAL PLUMBING ENERGY
Ihorwhicheby thi than them issed(Se.innlending agency ler the perfurmameuf 503 — FINAL MECHANICAL ENERGY
Ya the work for which this permit is issued(Sec.309].Civ.C.)
i W
Lenders Name
504 — FINAL BUILDING ENERGY
Z) Z LnaeraAaem 505 — FINAL ELECTRICAL
J Q 1 certify that 1 have mad this application and sero that the above information is
y Hcorrect.I agree to comply with all city and county ordinances and sok laws retailing m 506 — GAS TEST
Z)U bonding convection.and hereby authotlae representatives of this city ta=mer upon theFIN PLUMB G
W above-mentioned progeny tar inabscdon purposes.
LL
(We)agree,o save,indemnify and keep harmless the City of Cupertino against 018 F I L
Tq liabilities,judgmcn4 costs and expenses which may in any way same against said City
Jz in conequcncc of thc germing of this permit. 5
rats.;Wjillffic
PPLANT UNDERS SANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:5 ONG Date
NeZildIA Ac 2 Re-roofs 514 NAL PUBLIC WORKS
SignaturepplicanuCon,racmr ata -
HAZARDOUS MATERIALS DISCLOSURE Type of Roof '
e applicant or futurt builJing rK'eupam stare or handle hvardous material
the Cupenino Municipal Code.Chapter 9.11,and Re Health and Safety
zss3aa)] All roofs shall be ins ected rlor to an roofin material bei.�° P P Y g g installed.
c a licant or future buildin Occu quip If a roof is installed without first obtainin an ins ection,I agree to remove
nn g gam user mere or devices wnich g Ps air contaminants as defined by thc Bay Arca Air Quality Management all new materials for inspection.
❑Yo f-.18fao
1 have mad thc hazardousmamrials mquimmcnts un l rChapmr S95 of thc Califon
nia HcalN&Safmy COM.Sccduu255(15,]5533and2534.lunkm dthmiftM Wilding '
docs not currently hart a env 4 that it u my msponsibuhy in notify the acupam of thc
mqu mets icknorta =t dart, ceraCerdramor agony. Signature of Applicant Date
Gwnerar.tolum]edagrn, DZ All roof coverings to be Class"B"or better