03030081 CITY OF CUPERTINO ate"` �` "^`•.'.' `
BUILDING DIVISION PERA'IIT �C& =1tA.C`TUx Il'�k( I)tiVIA'ICIOI �° '
IMADR10 ADDRESS: HIGHLAND CONSTRUCTION AND `M,W'
0
0315 MARY PERw+ITka
NAME: 20073 NORTHCREST SQ
ROBERTA FLOOD
4082411858 SANITARY NO. C ENO.
ARCHITECTRIN01NEER: BUILDING PERMIT INFO
BLDG EIEC(- PLUMB MECH
17-7
LICENSED CONTRACTOR'S DECLARATION Job Description
I hmeby SMOG Nu I am licensed under provisions of Chapter 9(commencing
!� with Section 7000)of pjvislon 3 of the But ��aagggat two .and mylieenm is
hmurame a E /?ye REPLACE TUB/TOLIET/TILE FLOOR Data Conne�cta v H-or _ vtl5>r,
u JJ
I ARC at)to 'S 0E¢II,�TION
i Hund my Phu shell be rued public mnrds
i
ono Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby OfRm that I am exempt Bum the Commeures License Lew for the .�
.po followingmuan.(Sccdun 71G 1.5,Business and Professions Cade:Any city or county
$
which equine a permit to<mutrun,attar,Improve,demnllah,or repair any structure �B]L1ap
�^ prior to Its luunce,also requires the appllant formch permit to rile&signed sutamer, $ %U V Oon
s�< that be is licensed pursuant to the pmvislons or arc Comrutars License,law(Chapm9 Sq.Ft.Floor Area %U V O
(commencing with Section 7000)of Division 3 of the Business and Profusions Cnde)or
$ Wt k IS exempt daminum and as bssh for the alleged MuMP1IUL MY violation,of
Section 70315 by any applicant fora permit objects the appliael ta•ciWl pevlty Of 390H4100lbr- 0 0 Occupancy Type
.a.=than Ove hundred d.IUU ISsaD).
❑1,u Owner ar the pmpeny.ormy wployw wed w.ga u deb vele comp—don,
wllldothework,and Neawcwmuwtmmndedma(remdroruk(SM.70u.Busircu iui – FOUNDATqWkh Inspections
and ProreWna Code:The ContncmM1 Licause Law don Out apply an an ow..or
propenywhobuildsorimpmves thereon,and who dmaauch workhtmreaor through his 102 — PIERS
own employne.,provided that well lmprowmenuw not Intended oro0oed forsak.If. 103 — UFER
however,the building Or Improvement is mid within one you of completion.can Owner-
buildor will hew ore burden or moving that be aid not build or improve for purpose or 104 – REBAR
"U.). 105 - ANCHOR BOLTS
❑1,as Owner of the property.em exclusively contracting with licensed contractors m
construct the pmjca(Sec.7044.Business and Professions Code:)The Contractor's Ll- 106 — SEWER & WATER
was law does not apply to an owner of property arta bunds or improves therwn,and, 202 — UNDERFLOOR PLUMBING
who contracts for such projects with contneta(s)licensed pursmnt an the Counselors
Lkaanlaw. 203 - UNDERFLOOR MECHANICAL
exemptunderSea .B&PCforthISeuon 204 - UNDERFLOOR FRAME
Dale205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION
Ihereby afmmunder pewlyofperjury amOfineronawingaeelwhns: 301 - ROUGH PLUMBING
h.w.nawill msimmn.CeniEeeleSIC aman nito"Ir-wan rmrWmkeeSCUmpen- 302 - TUB & OR SHOWER
.orlon,as provided for by Section 3700 of the labor Code,for the performance of the 303 - ROUGH MECHANICAL
work for which this permit is Issued. 304 - ROUGH ELECTRICAL
❑1 have and will maintain Workers Compensation Insurance,as required by Salton
370D of the Tabor code.ser the performance of the work for which this permit is lama. 305 — FRAME
My we a am nor nInv..camm.ndPmlcyn , ratL(' 02 306 - HOEDOWNS
comer. Ncy VK 307 - INSULATION
CERTIFl COMPENSATION
NFRA WORKERS'
SO COMPENSATIONINSURANCH 308 - SHEETROCK '
(ITIS section need notbcconpktN Rest permit IS forow hundred dalhn(SI00) 309 - EXTERIOR LATH
mate"') 310 — INTERIOR LATH
I certify that in the performau of the work fm which this permit h Issued.I dull Hat
employ any person in any cement
an u an becomeanbject to the Wmkea'Compassable 311 — SCRATCH COAT
Laws of Caiifomia.Data 313 - ROOF NAIL
Applicant
NOTICE TO APPLICANT:If,after making this CcrtiOcste of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
,JZ become subject to She Worker's Compensation Provisions of the labor Code,You must
foMwithcomply with such provisions orthis Permit shall Wdarned revoked.
502 — FINAL PLUMBING ENERGY
zy CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
(hereby afRrm that Dom is aconsuuctimn lending agency for the performance of 504 - FINAL BUILDING ENERGY
oG�
the work(urwhich this permit uissued(Sm.3097.Co.C.)
Q lenders Name, 505 - FINAL ELECTRICAL
WM
5Z LenderaAaaea 506 - GAS TEST
UO I anifythat Ihaw read this application and SUM that Ne-how Information Is 507 - FINAL PLUMBING /
Yr torten I ago ta comply with all city and county urdinanas and situ hon entering ta
O buildingconswelion,anaherebyauthodrerepmentalmofthiscityInenteruponthe — FIWNG AL
{27 .have-mentioned property rid Inspection purposes
(we)agree to save,indemnify ad kap harmless the City of Cupertino against O FIn
y Ilabllia ,judgments.cosu and expenses which may In any way accrue sgdnnunl City U In con oaf egnnun this permit.APP U S ANDWILL COMPLY WIT}L�L NO -PINT Issued by: 5ORKS Date
_ Re-roofs
s' net of Ap un ON tin Data
HAZARDOUS Wilding
ALS tat m(whanE Type of Roof
WIIII applicantucwn future Municipal
Code.Chaptaorcor Mr the harsNommuriat
end by the Cupcmno Municial Cob.Chapter 9,12.SM the Health and Safety
Section 25532(e)7 All roofs shall be inspected prior to any roofing material being installed.
CI Y. Na
If a roof is installed without firs[obtaining an inspection,I agree to remove
w1ll the applleant at inure building Occupant new oquipmcot m devises which
It huardes air conuminanu"de0md by the Bay Arc&Air Quality Management all new materials for inspection.
inrkt7
(D Yes CPWo
Ihevee&d ah vamwsmetadaismquimmenuundcr .Chapmr6.95ofthc Celifor.
nla Hexlth&Safer adc,Sw ns253 25533md25534.lundenmdthstlfthebulWing
dos not cunni e t a u my eapoulhlll odfy tM Occup t nr tic
Maui n r IauanceOFsCcmOna r e 3 Signature of Applicant Date
owner id., m r t All roof coverings to be Class"B"or better