02050191 CITY OF CUPERTINO z °'" sem,• tl '�-- ""
BUILDING DIVISION PERMIT '�CONTRAC®TORINFORMATION:
BuB1l8ca gEsM4ARY AVE BALCH PETROLEUM INC PERMIT Nl02050191
)C,;JJ (CITY OF CUPERTINO) 930 AMES AVE APPLICAT`"r3�V 2002
IONS:
(408) 942-8686 SANITARY NO. // // CONTROL NO,
ARCIIITECDENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
t-00 LICENSED CONTRACTOR'S DECLARATION �y��crr�I�� w, q,
c� Ihcrcby affirm Natlam licensed under provisions of Chapter 9ltmmmenciog INSTALLATION C�E' AN"i'La'NNH�,,Va+��, �
5<e with Section 700(huf Divisinn3of Ne Basin, and Professions Ctde.aMmylicerra is
Font fulllivice n c t. . /
of�= Lieen Clasr _�Lie. t% JAN $ 8 2003
-o Dal k Cnm[[��I}(r J
Gifti ARCIIITIiLT'S[jpE1.A TION
w y 1 understand my plans shall M used as public records
FLL0 LicensedPonessinbil �111i,DING
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Cunlnctor's License Law for the
$110000
ad a O fallowing reason.(Semon 703 1.5,Business and Professions Code:Any city or county
X2 which requires a permit to construct.eller,improve,demolish,or repair any siucmre
Fit prior In its iomanee,ithm recoics the applicant for such permit no fleasignedstatement
< that he is licensed pursuant to the pnsvidurrofthic Contractor's License Law(Chapmr9 Valuation
y�Q (commencing with Sectionll"a it Division 3ofthe Wsm,ssand Professions Csde)nr
Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty mf
nmo
mine than five huadreJ dollars($5,10). 10 2 N-N PIERS
Jf'6RT0AT1 UN Occupancy Type
0 1,as owner of the property,or my employees with wages as their sale compensation,
will Jothe work.and fee structure is not intended oroffered for sale(Sec.7840,Business -
and Pm rautim Code:The Contractor's License law Jas not apply to an twat of 104 - REBAR Required Inspections
property who builds or improves themon,and who doessuch work himselfor through his
man employees.provoked that such improvements au not intended oroRered for sale.If, 105 - ANCHOR BOLTS
however.Ne building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving Nat he did not Wild or impose for purpose of 106 - SEWER & WATER
.It.)' 202 - UNDERFLOOR PLUMBING
❑L as owner of the pmpeny.am exclusively conducting with licensed contractors to 203 - UNDERFLOOR MECHANICAL
compact the project(Scc.70a4,Business and Professions CoJC:)The Contractor's Li.
se Law Jas not apply to an owner or property who Wilds or barrows themon.and, 204 - UNDERFLOOR FRAME
who commets for such projects with a contractor(&)licensed pursuant to the Contractor's
License Law. 205 - UNDERFLOOR INSULATION
O l am exempt under Site ,B At P C fan his reason 301 - ROUGH PLUMBING
ser Data 302 - TUB & OR SHOWER
WORKER'S COMPENSATION DECLARATION 303 - ROUGH MECHANICAL
I hereby affirm under peachy of perjury one of the following declarations: 304 - ROUGH MECHANELECTRICAL
1370)
have and will maintain a Cenifrcam of Consent self-insure for Worker's Camper.
n,a provided for by Section 3]1X)of the Labor Ctdc,for the Performance of the 3 05 - FRAME
k for which this permit is issued. 306 - HOLDOWNS
have and will maintain Worker's Compensation Insurance,as"fired by Section 3 07 - INSULATION
of the labor Code,for the performance of the work for which this permit is issued.
Worker' Cnmpensatinn msumnce carrier and Policy number am: 308 - SHEETROCK
a cr. i7«22 �o"v-+-� Politt�q.�l� �y(001115q�
CERTIFICATE OF MEM to lf(OMWO K— ERs 309 - EXTERIOR LATH
COMPENSATION INSURANCE 310 - INTERIOR LATH
(This acetum need nor W completed iOW permit is Orion,hundred dollars IS 100) 311 - SCRATCH COAT
less) 313 - ROOF NAIL
I cenify that in the performance of the work for which this permit is issued.)shall not 501 - FINAL ELECTRICAL ENERGY
employ any pemo any manner so sat it)become subject o the WorkerYCompensndion
Lawaofcafformiate 502 - FINAL PLUMBING ENERGY
Applicant
NOTICE TO APPLICANT:Ir,alter making this Ceniftisle of Eaempdinm.you should 503 - FINAL MECHANICAL ENERGY
Wconic subject to the Worker's Compensation provisions of the Labor Co de,you must 504 - FINAL BUILDING ENERGY
OO forthwith comply with such provisions lir this permit shall he deemed revoked.
z
CONSTRUCTION LENDING AGENCY
505 - FINAL ELECTRICAL
I hereby affirm Nat there is a construction lending agency for the imlonanoce of 506 - GAS TEST
a ? But work fur which this permit is issued(Sec.X07.Civ.CJ.Name
Lead1507 - FINAL PLUMBING
1L Z
70Q Leaders Add.. 508 - FINAL MECHANICAL
U 0 I certify Nat 1 have read this i pplicmion end ante that the show informmion is 509 - FINAL GRADE
V, i~ coned.I agree to comply with all city and county HNinances and stare laws relating to
C) building construction,and hereby autharim representatives of this city to enter upon the 5 FINAL PLANNING
Wshoe-memthmed pmpenyI inspection pupims. 14 FIN URLT W RKS
(We)agree m...indemnify and keep haml
ress Inc City of Cuperlino against
sF's l�/1 liabilities.judgments.costs and expenses which may in any way acme against mid City 6 O OO NAIL J
U z IAnPPI CyANcc of DERSgranting sf thts DPermit.WILL COMPLY WITH ALL NON-POINT Issued by60 F o �-
'jrpp Date
SOUR EG TIOtB . Go `J.U� _
7 _t Re-roofs
lamc of Appl,e up'
ZARf'Dmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicam or fuwrc M1uilJing wcupam amrc or handle heaarJous mamtlal
define)by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
e,Sec too 25s3xa)3 bor, All roofs shall be inspected prior to any roofing material being installed.
❑Ycx
Will the applicam tar fumrc building acupam use cyuipmem lir Jcviccs which If a roof is installed without first obtaining an inspection, I agree to remove
coil hacurJads aiscumamimsnts ns lined by the Bay Arca Air Quality Management all new materials for inspection.
Di.aricty
❑Yes
1 have mad the M1esmdous materials requirements under Chapter 6 95 of Ne Califor.
mixllcalth dt Safiety Cock.Sectione,15515,25533 and 25530.1 understand NaiftM Wilding
it..,not currently hae a¢ y respnaihiliq m nodry rbc acupam of rhe
m mems hichm mmprinr IssuanccnfeCcnifica ar0.casncyy. SignatureofApplicant Date
s Q .
or lir authorised agent Doc All roof coverings to be Class "B" or better