03050155 CtI'Y OF CUPERTINO �n
BUILDING DIVISION PERMTT (QNTRA_TQR INF,QRMATIQN
BUILOp'GADDRPSS: CLAIBORNE CONSTRUCTION PERMIT
691 T-OMTTA All
RSNAME: 4638 HEDGEWICK AVE PERMITISSUEDATE
STEVE & JENNY MA W 08/11 /2003
:
(5 1 0) 651-1820 SANITARY N0. CONTROL N0.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MPH
+oa LICENSED CONTRACTOR'S DECLARATION
0 0 0
iI hereby art,.that 1 on licensed under pravisions of Chapter 9(commcmeing Job Description
,i with Section 7=)).r Division J of Ne Bu sand Professions Code.and my hot,c is
.o w in full foo: a fees. fie}
,qg Lot" t I Lex e ADD 865 SQ. FT. /GARAGE 240 SQ. FT.
',_O Dr. Can
ARCHITECTS acw ITCHEN & MS BATHRM REMODEL
FF'y ARCHITECTS DE RATION
my plans shall COPY FEES $21 . 60 PAID (07/21/03)
2 W u 1 undenunJ M used es public records
,a
:�� Liccnud Pm(cemnnal
5 OWNER-BUILDER DECLARATION
'i a y I licichynaso affirm on 11, exempt from the Comrns Co License Lew for the
o O follwhnwi ng rcama.(Scotian IIDI.0.Business and improve,
do i oli Code:Any city structure county
5= which require.a permit m cammruet,eller,improve,demolish,fir repair any laMmum
triton incensed 0.al.untto ma the applicant for such Contermiuo sle a ense Law(Cha mem 114
F� that me cttnud pursuant h)provisions of the CanwcLicense Law(Chapter Sq. Ft. Floor Area ualion
$ (cat he is(commencingwithSection T(and theof basis f r the
the ageBusiness xmpt on,Anyfit,imea eti, r
..
that he is exempt thcrtfrom end the baso for the alleged cxempuon.Any violation ofkLALi_ $150000
Section IIm 1.Sby any dollarorepesmit subjects Nc applicanuo ecivil penalty of APN Number JJ re pansy Typ
not more than five any apdiantfor R poo ��`7 e
❑ 1,as owner of the property.Or my cmPlOyeee with wages as their sole compensation, 35717023 . 00
will do the work,and Ne swetme is not intended or offered for sale(Sec.7W.Business
and Pmressionn Cade:The Contractors License Taw does not apply to an Owner of Required Inspections
property who builds or improves thereon,and who doessuch work himself or though his.
own employees,provided that such impovcmenu me not intended or offered for Sort.If, 101 — FOUNDATION
however,the building or improvement is sold within One year of completion.Ne owes
builder will have the burden of proving Nat he did not build or improve for purpose of 102 — PIERS
sale). 103 — UFER
❑I.a owner of the Sec.ponmony,70,1 .B sinessvnd consorting with licensedcontractorsto
condom thees not (Sec.70,1d.Business and Professions Codc:)The esnoacmrs Li 104 — REBAR
cense who comwdmsr Such plyomowner ith aontproperty ctino who sedpurlds rimpfothe theeon,antl. 105 — ANCHOR BOLTS
aha contracts for such pojccu with o cnntractor(s)licensed pursuant to the Contractor's
1sLicenaeexe 106 — SEWER & WATER
❑Ism exempt antler Sec. Date for this ,on 202 — UNDERFLOOR PLUMBING
r WORKER'SCOMPENSATIONDECLARATION 203 — UNDERFLOOR MECHANICAL
I hereby alarm under penalty of perjury one or the fallowing declarations: 204 — UNDERFLOOR FRAME
176D
awand will maintain.CimineweofConsent 1..1Nnaumfor Workers Compen- 205 — UNDERFLOOR INSULATION
,as prOvid tel for by Seetioa 37(k of the labor Cade,far the perfomnnacc 9f the 3 01 — ROUGH PLUMBING
andwilinpamniinWorer' 302 — TUB & OR SHOWER
ave and will maintain Worker's Compensation Insurance,as eyuirctl by Section
aflielaborCode,fortheperformanceoftheworkforwhichthislutmu0aissued. 303 — ROUGH MECHANICAL
orker's Compensation Insurance carrier antl Policynumher arc: 304 — ROUGH ELECTRICAL
n: �j�� Poli O.:
CERTI�ICATEOPEK EM141 FROM WORKERS305 — FRAME
COMPENSATION INSURANCE 306 — HOLDOWNS
or Ins.)(This section need not bceompleud ifthe permit is for one hundred dollars($101 307 — INSULATION
1 certify But in the performance of the work for which Nis permit is issued,1 shall not 3 08 — SHEETROCK
employ any person in any mannerso as to become subject o the Warkeri'Compcasadoor 309 — EXTERIOR LATH
Law.of California.Date
APPlicant 310 — INTERIOR LATH
NOTICE TO APPLICANT.If,aper making this COmficate of Exemption,you should 311 - SCRATCH COAT
Wco fit Subject o the Workers Compensation provisions of the labor Code,you must
.J z forthwith comply with such provisions or this permit shall be deemed revoked. 313 — ROOF NAIL
zO CONSTRUCTION LENDING AGENCY 501 — FINAL ELECTRICAL ENERGY
F Ihereby forwhihhithenthem i.aed(Sec.3097,lending agency l'nnhcPerformance of 502 — FINAL PLUMBING ENERGY
(Yi the work for which his tennis is issued(Sec.J(NT,Civ.C.)
i C1 Lcndcr'aNemc 503 - FINAL MECHANICAL ENE
Z LndersAddmus 504 - FINAL BUILDING ENER
V Q I minify that 1 have mad this city
and County
and Marc that and above ws Mruiun i.
py F comcet.1 agree to comply with all city and county uulives of and State laws elating to 505 — FINAL ELECTRICAL
U anowngeonswnion,and hereby euthoriu rcpresenutives of this city mcnler upon the GAS EST
attovcmcntianed popery for inspection purposes.
F y (Wc)agree to Save,indemnify and keep harmless the City of Cupcnino against 07 FIHabiLN
Uh incoitiesjudgofthe costsandof this csmit. may inany way accmc against said City 5 ICAL 2
V z to eonuyucnec encs.granting exisis Permit. f /
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:5 Dale
SOURCE REGULATIONS.
Re-roofs
instant afApplicanUContractor Dau 5 .4 INAL PUBLIC WORKS
HAZARDOUS MATERIALS DISCLOSURE Type of Roo
Will Nc applicam or future building orotate not Or handle haraNuus moonset
as defined by the Cupeni no Municipal Code,Chapter 9.12,and the Heal@ and Safety
c,Section 355J2(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yet �XNO
/ Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t herardous air conumimanu u defined by the Bay Area Air Quality Management all.new materials for inspection.
isuln?
❑Yes o
I have rtad lu
Me ra nusmatcrials requirtmenu under Chapter 6.95orthe Cariboo,
.is Hear th&SofayCodc,Sections25515.255]3 and 255X.l understand tow if the Wilding
docs not a mend,have a unam,that it is my responsibility to notify the mention of the
requirements which must be met ryior tet issuance of a Ccrufcau or Occupancy. Signature Of Applicant Date
8 q\-o
RPmautharindagcnt D„e All roof coverings to be Class"B” or better