02010124 OF
NO
ci BUILDING DIVISION
PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10555 MARY AVE 02010124
OW NEWS NAME: APPLICATION SUB DATE
CITY OF CUPERTINO 01/30/2002
9 PHONE: SANITARY NO. CONTROL NO.
s z ARCHITECUENGINEER: BUILDING PERMIT INFO
to FOF R DG ELECT PLUMB MECH
�<u`i C J CJ LJ I"'I
m Z LICENSED CONTRACTOR'S DECLARATION Job Description
Gz y o 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing CANPY METAL BULDG. p
F= 5with Section 7")of Division J of the Businessa Professions coda and my licenseL('(
Lim full far d t. �I
Spit License Cl f-TCL#'N_ tZ� �
M
Da`e, Cant {'i::V-^ e +( 1 i+'�
3 a. J. ARCHITECr'S DE LARA 10. ` �
G a O g 1 un 2: my plans shall M used as public records
w pc Licensed Professional
c n. OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License law for the
following reawn.(Section 7031.5.Business and Professions code:Any city or county. $38 50
0
IFC which requires a permit to construct,alter,improve,demolish,or reWir any structure
i3$ thitttos,limuaed pursuntto the provisions
fthe Coutiarmiuoicense aw(Chaptem. - --- --
(com eaci gwithurzuknno00)of ivisi n3 ofthntmdmssandnselawonsCo e) S FL Floor Are Valuation
or that :N with Section 6m anof Division I of the le jed!ess and Profusions Code) S`p•+;,t�•(•y?9'i f d•• Y.a i l3 i'..•:::�S t+,s •+
or that he k 31.5 bythemhom•anJ the basis for the subjects
thdvA Nanta to Any violation I
-of nSection o,..,ban
vanyapplicantfur"permit subjectsthe applicant mecivil Penalty
nr)mmnrema)fvehandled aouars(ssW)' 101AFNV"DATION it. '" � - Occupancy Type
01,as owner f,he property.Lir my employees with wages as their sole compensation
-
--will do the work,and the structure is not intended or offered for'sale(SCC-]OM1:'
'Business and Professmns Code The Conn..,',License Law does nm apply 1n an 103 - UFER Required Inspections '•-E"r
or through
owner of property Who builds or improves thereon,and who does such work himself 104 -_ REBAR
or through hie own employees.provided that such vement improvements arc not intended or
-offered far.sale w h -th-building t mP of i s sold that h Slim not Wild of ........._ ., .. . _-. .. L ., _ ... _
eomPle(on,the owner-Wilder will base me burden nr that he not baud or 105 - "ANCHOR BOLTS "+ • '
improve for purpose oriole.). proving -
106 SEWER & WATER I
01'i.'oF e:or,t6eproperty.:m<x-iarfvelYeontmntinewithiicensedcowomet,o _..._..__. -202 ' -UNDERFLOOR- PLUMBING' ___,r,r :. ._... ._._...._....._. _.._._...
construct the project fsec.]ou.Business and Prnressions Code:)The Contractor" 2 0 3 - UNDERFLOOR MECHANICAL' "'.
10 License Law docs not apply m an owner M propeny who builds or improves thereon,
_and,who contractsfol.sueh.projects with a.mntrictoos)licensed pursuant to.the
_.._.__204- UNDERFLOOR FRAME — ..___.__.._..._.._..._. ......_._... .._.
Contractor's mtunder
taw.,..
❑laexcmpt Sec.. ' I'' ," �.B&,PC formisrtason 205 - UNDERFLOOR"INSULATION
Owner "' Date' "" 301 - ROUGH PLUMBING
rr
WORKER'S COMPENSATION DECLARATION 302 - TUB tk OR SHOWER
I hereby affirm model penalty rdpe,jury mc..f me following decmrstinne: 303 - ROUGH MECHANICAL
0 1 have and will maintain a Cenifcaebf Claim,to self.imme for Workers 304 - ROUGH ELECTRICAL
Compensation, as-provided for by Section d]W of the Labor Code, for the
mormanceofthe work rorswhich this remit isissued., 305 - FRAME
- ❑1 have and will maintain Wm1m,'s Compensation Insurance,as required by Section 306 - HOLDOWNS
- - 37b)of he Labor Code,for'he poffo rruirtc ofme work for which oda peri.,i" 307 - INSULATION
"sued �M W)he's Compe sato 1 sura)a corner and Pit icy number
rat 308 : _.v..... .. . ..o._ .. _. _..-..-.__..
f6y.2r13�p "' - SHEETROCK """ 'j'
Cam .i_ r Imy No - r.-
Lt , CERTIFICATIONOF ' FROM WORKERS—
COMPENSATION
ORKBRB
COMVENSATION'INSUR..... f ��I.++ 1 +3 O 9 �E•';•EXTERIOR.'..ILLAATTHH.j'.._,.
_.,. -
It I
__.,._....r„.,.
(Th s sen on need not be complete)if the porissri is for one hundred dollars 311 -, SCRATCH COAT
!-,c e a i ry-t ha I I a t h c-Wr OT ma-e c-0 ft krr h inm permts .auad,I ' '3.13 -ROOF- NAIL - ' - - - `._-, . - - - -.-
:nnu not empl,y any pc ed in any map) au n,ne.mmc, b)ee!io the Wnrkere 501 - FINAL ELECTR I CAL t ENERGY
Compensation Laws of California.Date,'
Appfcant - '• - - - .-- - - . 502 .----FINAL—PLUMBING- ENERGY .. ._....._
NOTICE TO APPLICANT N.after making this Certificate of Exemption,you should 503 - FINAL MECHANICAL\ENERGY ”
O � bec8me:;object to the Wmker'i Ci,nFensmino fnnwikiuns of the Labor Code,You mail
fnnhwitncomplywimaachprevi.sionsorthisPermitshallhedeemedrevoked. _ ___ 504 r..FINAL -BUILDING_ENERGY-- _ _
Z 'ft t 'CONSTRUCTIONLENDINCAGENCY 505 - FINAL ELECTRICAL :
�.. I K by ff di t th n i i dung agency fo ih'pc f nmuncd - +'
oft) krwhichod x issued(Sol.3W],Civ.
c) 506 GAS TEST
0. .Lea Ald,c,, 507 - FINAL PLUMBING
U0 1«rtf,tha Ihae adthisopplic.mmindstemmanM1cabovcmfomutionis 508 - FINAL MECHANICAL •r
auirea 1 g-emc )ply an I county ordinances and state laws relating509 - FINAL GRADE
O V tobuilding construction.andl reby authorize mincientatives ofthityt t pun
Iy� the above p p.nyf inspection pr{wse 510 - FINAL PLANNING
A.
(Re) genet "oe indemnifydk anph,mles theCty f&penmoopons,
W fowl t I dg tc ...c and p es which may n any y mainst said 514 - FINAL PUB I;-MCI
lS!/
U.Z" City n c of th m yycf'Ihi n
APPL - TUNDIH STA )$A\DWI CO\IDLY WITH ALL NON-POINT
sou•ce REcuLATrorvs. tissued by: ate
igopure,of ApplicantlContmcmr .•,r ',! '.1 Dole Re-roofs /
Ss HAL GidUS MATLRI is DI LOSURE
wu m ppl ca t o f t m b lding a tare or handle hax,ud n material Type of Roof._.. ._.. ..... ,,. -..__ .__
'os dstn Jby th Cpen no Al pIGW Chapter912.and ole Heald,and Safety
Cone.
one"Chad 2...21 rat ,r TI "j et"•- t + ?'• Y k tsf,-fes`!
+oY • + ,+;IoN ;•, 5, • t , All•roofs sball be inspected pnor_to-any roofing-material being,tnstalledt
Will the allplicam orfuture building gamy:eequipment or devices which If a roof is insialled:without first obtaining an inspection;"I'agree"to remove
ends
h ado"s air inn t.m defined by theBay Area Ail Quality Management
Dioerer o, all new materials for inspection. Applicant understands and will comply with
_.... oven . 'pN..- i,. .., ... _ - ._
tt , " - all non-point source regulattonr.', •: 1 . tr
tuna read the Aazardous'mmcrials requirements Lia&,Chap...6.95 of the
Cuff Health At Salty Cod secunn2$50515513 and 25534understand Nat
fttiebald' gd est cue yhavnt mitis my re Po sbltYt,nmify the
occupant f I uirem ss 'hsch molt bc/fi t p or to issu cc f C infect a of
Do, p \) Signature of Applicant Date
.: l�
tuner or acts ,gen,. D„ All roof coverings to be Class"B" or better
-OFFICE... _ .. .. _ . ._.. .. _.