03040073 CITY OF CUPERTINO .....
Ry 1.pBUILDING DIVISION PERMI +C
VONTRACTOR INFORMAT�I,,,
LIOLb°�RWIN LA ax w PERMITNO.
03040073
r t� �" L & THERESA GLAZBROOK PE ° '95T714/2003
J SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG E
ELECT PLUMB MECH
0 0 0
+oo LICENSED CONTRACTOR'S DECLARATION '
� F❑ I hereby affirm that I am liwased under provisions of Chapter 9(commencing Job Description
z Its Swu n7")ofDivision 3ofthe Business and Professions Code.and my license is
a<y in full farce and effect.
License Class Lic.n ADDITION/REMODEL
"° Do —TSDE L REPLACES PERMIT 26619
a F n ARCHITECTS DECLARATION cc ww..
wasIundcaundmypmnashmlbeumdaspublicrecords (OLD SYSTEM FROM 1994) FINALVp
°o y Licensed Professional '
OWNER BUILDER DECLARATION SEP 2 8 2003
a I 1 hereby affirm that I am exempt from the C°mncmr's License Law for the
00 following mason.(Section nn I.S.Business and Professions Cade:Any city m county
5 which requires a permit to construct,alter,improve,demolish,or minor any structure
-Zy prior H its issuance.also requires the applicant forsaeh permit file a signed statement Rea
< HmhcisliccnmdpursoonuotscpmvisionsnfthcConvumr'aLicenselaw(Chapter9 Sq. Ft. Floor Area
Vit=° (Commenting with Section 7")of Division 3 of the Business and Professions Code)or
that he is exempt therefnm and the basis for the alleged exemption.Any violation of
Section 7031.3 by try applicant far a permit subjects the applicant to a civil penalty,of ApN Nb �9�BaP3Y YP
not more thaNumber n five hundred dollars(SSW). Type
D 1.ax;owner of the pnpcny,or my employees with wags as their sole Compensation,
will asthe mak.and tsc structim is not intended or offered for sale(Sec.70,11,Business 35923010 . 00
and Professions Code:The Comment's License law does not apply to in owner or Required Inspections
progeny who builds or impraes Hereon,and who does such work himself.,through his
Own employees.provided that Such improvements are not ntended or offered for sale.It, 101 — FOUNDATION
however.the yeas building or improvement is mid within am yeof completion,the Owner-
Wilder will have the burden of proving that he did not build or improve for purpose of
mm.). 10 2 - PIERS
D I.as owner of the properly,am exclusively contracting with licensed contractors n 103 — UFER
contrathe project(Sec.70,1,1,Business and Professions Code:)The Contractor's Lt. 104 — REBAR
ceee Law dors not apply in an owner of properly who builds or improve thereon,and.
whocunmcts for such projects with a contractor(s)licensed pursuant n the Contractor's 105 — ANCHOR BOLTS
Lnm Law. "' '' 106 — SEWER & WATER
4.��wdl
nnesetn'som lin See. ,B A,P C for this moon
1z' Date =/ -202 — UNDERFLOOR PLUMBING
WORKER'SC ATIONDECIARA 203 — UNDERFLOOR MECHANICAL .
I hereby affirm under penalty of perjury oe of the following declaration: 204 — UNDERFLOOR FRAME
11 wvtImaintainaccnlBCateorConseatnself.inmrofarWmkertCompen- 205 — UNDERFLOOR INSULATION
satiate,as provided far by Section 37W Of He labor Code,for da Kdarmace of die 3 O 1 - ROUGH PLUMBING
wart for which His pct ra is issued.
❑1 have and will maintain Workers Compensation Insurance,as required by Section 3 02 — TUB & OR SHOWER
37W.1 the tabor code.Tor c.performance of the work ria,which this permit is issmd. 303 — ROUGH MECHANICAL
My Workers Compensation insurance Carrier and Policy number am: 304 — ROUGH ELECTRICAL
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' 305 — FRAME
COMPENSATION INSURANCE 306 — HOLDOWNS
m
less.) section need not ta Completed lithe permit is Abuse hundred dollars($100) 307 — INSULATION
I cenify that in the petition 'C
e rmma'ece of the wort far which Hix rmIt is issued.)shall out 3 08 — SHEETROCK
employ any person in a,104W WC cs tMWorkcriC neati°n
Lxwsor brag, Y PT °m"` 309 — EXTERIOR LATH
Ap 310 — INTERIOR LATH
N0T1 O APP 1 Y. On this Ccnircam of Exemption,you should 311 — SCRATCH COAT
beep" subject to the Worker Compensation provisions of the Labor Cole,you maw
]Z forthwith comply with such provisions or this permit shall le deemed revolted' 313 — ROOF NAIL
z� CONSTRUCTION LENDING AGENCY 501 — FINAL ELECTRICAL ENGY Y v�
1 heathy"from that Here is a coesuuctinn lending agency far de perform race of
X> He work for which this permit is issued(Sec.3W7,Civ.C.) 502 — FINAL PLUMBING EN
Feader's Name
Lcnd<h Address 503 — FINAL MECHANICAL E G
zlz
I Certify that 1 have red Nis application and sum that He above information is 504 — .FINAL BUILDING .ENER
yFcorrect.Iagree tocomply with all city and county ordinances and sutelaws feeling 10 505 — FINAL ELECTRICAL
�U budding Construction,and hereby anhadre,ePresenutives of His city to Cater upon the GAS TEST
N "bow-bandoned property for inspection pugwms. —
r py (We)agree to she,indemnify and keep harmless the City of Cupenum against 0 _ F I
N liabilities,judgments cost and expends which may in any way acerae against said City 5 z in Consequc graining of tsis fcrmit. Lgf4^ APPL T U ERSTANDS PLY WITH ALL NON-POINT Issued by: _ Date
50 CE RE S.
' -� Re-roofs 510 P
NAL PLANNING
attire of Applicant/ r Den - KS
HAZARDOUS MATERIALS DISCLOSURE Type of Ro�f 14 FINAL PUBLIC WOR
Will the applicant or future building Occupant store or handle haandous matenal
as defined by the Cupenind Municipal Code,Chapter 9.13,and He Health and Safety
Codc,Sce ion 35532(1)?
Dyes Iii; All roofs shall be inspected prior to any roofing material being installed.
wit the applicant or future buildingowu ant use If a roof is installed without first obtaining an inspection,I agree to remove
p a Air Qu or Maras which g p
.{ .haevdnus air conmminanu az defined by the Bay Arca Air Quality Management all new materials for inspection.
1` ,uric? _
Dyes f9
1 have mad thc humblous materials mquimments under Chapnr695 of the Califor-
Id'.s,
CaltsYSxfcty Codc.SCctiart 35505,2553Jmd .londcrsundthatifthc building
tea cu me a enank HnI ii is iIfYmnod ly tie scupmt of the
mm w h me of a Certificate ofOcCupmey. Signature of Applicant Date
cru aumo7c pg D„�y All roof coverings to be Class"B”or better