03080100 77777
CITY OF CUPERTINO
Bun. -77-7777777—
mrvc Drvlslory PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS: SON R CRASE CONSTRUCTION I 611T No03080100
R'S NAME: 164 GILMAN AVE PERMIT1SSUEDATE
PHONE: (408) 370-1485 SANITARY O. CONTROL NO.
ARCHITRCTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
!Oo LICENSED CONTRACTOR'S DECLARATION lob Description
iC I hereby affirm that 1 am littascd under provisions of Chap Y(commencing p
b wish Scmion]IXNBofpiviion3ofthc Buamassan Pra ss m dm liccnmis �,w,� �D
a in full forec and t. N
Licca us G Lic.N KITCH. REMODEL
F O Dme a - Cuntranor
pp tummy HITECTS DEC ARATION ,g Q 9
2 N< 1 understand my plain shall be used as pts lie records V O 4 2003
JyD
Licensed Professional
OWNER-BUILDER mreptfrom
DECLARATION BUILDING
e I I naso ,(Orin that 1 ore exempt fain Ne Canton Co License Law fur the
p O fallowing reason,(Section]1131.5.Business and PnNeexio li Code:Any city or county
e m� which inquires a permit m construct,abet,improve.demolish,or repair any structure
O!v, priori its issuance,also requires the applicant for such remit o file a signed statement
< that he is licensed pursoonunthe pmvision.of the CmurseturaLicense Lave lChapler9 Sq. Ft. Floor Area Valuation
e tlC2 (commencing with Section 7000)of Division 3 of the B usiness and Professions Code)or
03$
that he is exempt therefrom and the Ensu for the alleged exemption.Any violation of 35705051 . 00
Section 7031.5 by any applicantfor a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
net mom Nan five hundred dollars($500).
[]I,u owner of the property,or my employees with wages as their Bole compensation,
will do Ne work,and one structure is not intended Or offered Wasik(Sec.7W,Business 101 - FOUNDA1 d inspections
and Professions Code:The Cootnemrs Limine law does not apply to an owner of
property who build,Ofimproves Nemon,and who does such work himseBor through his 102 - PIERS
own employees.provided thstauch improvements are not intended of offered for sale,If. lO3 - UFER
however,One building or improvement is sold within unse year of completion,the owner
builder will have the burden Or proving that he did not build or improse for purpose or 104 — REBAR
sale.).
105 - ANCHOR BOLTS
E]1,as owner of the property,am exclusively contracting with licensed mnlracurs to
consmuci the prOceL(See.7094,Business and Professions Code)The Contncmr's Li. 106 - SEWER & WATER
came law does not apply in an owner or property who Wilds or improves thereon,and, 'ZO2 — UNDERFLOOR PLUMBING
who contracts for such pm)eco with a contractor(&)licensed pursuant to the Contractor's
License Law. 203 - UNDERFLOOR MECHANICAL
❑ 1 am exempt under Sec. B&P C for this reason
204 - UNDERFLOOR FRAME
Data
WORKER'S COMPENSATION DECLARATION 205 - UNDERFLOOR INSULATION
a I hereby affl m under Penalty of Perjury one of Nc following declarations: 301 - ROUGH PLUMBING
I have and will maintain a Certificate of Consent to selGinsum for Worker',Compcn. 302 - TUB & OR SHOWER
mtien,as provided for by Sce ion 3700 of Ne labor Code,for the Performance of the 303 - ROUGH MECHANICAL
work for which this permit is issued.
1 have and will maintain Workcra Compensation Insurance,as required by Section 3 04 - ROUGH ELECTRICAL
37W of the labor Code,for the performance of the work forwhich this permit is issued. 305 - FRAME
My Worker m nse/t�ion lns�u aan�a carrier and Policylicy numbers 306 - HOLDOWNS
6rricr. PoNo.: 0
CERTIFICATE OF EXEMPTION FROM WORKERS' Z'p;'
307 - INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
lcssless.)ITU
( section need not he completed i0hc permit is for ane hundred dollars($100) 309 - EXTERIOR LATH
fir
1 cenify Nat in the perfomtarsc of Ne work for which this permit is issued,l shall not 3 10 — INTERIOR LATH
employ any pcmon in any manner so as to become subject o the Workeri Compemalion 311 - SCRATCH COAT
Laws.fApplicant California Vale
313 - ROOF NAIL
L.wa
NOTICE TO APPLICANT.If.after making this Ccrifteste of Exemption.you,hould 501 - FINAL ELECTRICAL ENERGY
become subject to the Worker's Compemadma provisions of the Lather Code,you must
0 z forthwith comply with such um,ishnsorthis permltxhall the deemedrernked_ SO2 - FINAL .PLUMBING ENERGY
z O CONSfRUCfIONLENDINGAGENCY 503 - FINAL MECHANICAL ENERGY
[-� Thereby o(fnm that there its convection lending agency for the performance of 504 - FINAL BUILDING ENERGY
!Yi raw Ne work for which this pamir is issued(Sec.3097.Civ.C.)
IA p Under Name 505 - FINAL ELECTRICAL
5 z Under.Add.. 506 - GAS TEST
U O 1 ccnify Nat 1 have read this application and state that Ne above information is 507 - FINAL PLUMBING
Lk. P correct 1 agree to comply with all city and county ordinances and state laws relating to
0U building convection,and hereby authorim representatives of this city to enter upon the FIN MECHAN CAL
6W. ahovomcntioned pmperty,(or Inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against 0 9 FIN
.F.a to Iiabilides,judgments,costs and expenses which may in any way accrue against said City his tron it. 5 NG
of the gothung Or
U Z APPL CANTcUNDERSTANOSrAND WILL COMPLY WITH ALL NON-POINT Issued by:5 WORKS Date
URCE= t9 Re-roofs
Signature of h"O"Common' Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof .
Will qu.pplic.int or future bulldingoccupanumm orhmblc hismadous material
as defined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
Section 25532(.)7All roofs shall be inspected prior to any roofing material being installed.
❑Yea
Will the applicant or fu u wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for Inspection.
Distrim7 _/
❑Yes s
1 have read up,Iwzardeus materials req.mmu fits under Chapter 6.95 of the Calif.,.
nix Health&Sadly Cole,Sections 255115.25533 and 25534.1 understand Nat if the building
dins not currently have a tenant Nat it is my responsibility an nouly the occupant of the
mquimmcna hie pdor,,asuanceor.Ccruficataoffupapcy,� Signature of Applicant Date
rl
vent,fir au iced agent pate All roof coverings to be Class"B" or better