03040105CITY OF CUPERTINO�'�`
,
BUILDING DIVISION PERMIT
XONT GTOWINFOR.MAT�TON
ik !t Y\.. fr£k.n.f!e�R.`vZ.�#
Bu'DING ADDRESS:
HAMMERSCHMIDT CONSTRUCTION
PERMIT N003040105
:R'S NAME:
1574 COUNTRY CLUB DR
FEEMETESOYj"�ii2/2003
.::ARA SLEE OKADA ORVENA
NE:
65,0) 948-4200
SANITARY NO. CONTROL NO.
ARCHnECOBNGINEER:
BUILDING PERMIT INFO
BO ELECT PLO MECH
O
p LICENSED CONTRACTORS DECLARATION
Job Description
I hereby aRlrn Nal l Am licensed under provisions of Chapter 9 (commencing
-
with SAW. 70110) of Dlvbian 3 of the Bushaessand Pruf.m. Code,Md my [let. 1.
I. full (cmucMdefrcot.
REVISION --IN HOUSE USE ONLY
_
Leann Class Com
Date Command,
lltlC
NO NEW PEMRIT ISSUED, ORIG. #01030001
ARCHf1ECTS DECLARATION
1 undcntand my plans.hall W used As public mcwaa
�<
Licensed Professional
OWNER-BUILDERDECON
^�
I rehy, .Ruexemptm ]hal 1 see exempt from thee Connoccor's Lkenre for the
M
city
ons Code: Anytily
O r county
7031.3. Cot o
Andnpa
reason.d.APermit
whicrAllnh
Mmmu.
slue improve. Jeermitt nrea sir any nneture
�a which mqulrtu 4.1mr.s ve. do
Permit he cdreS
n duo
to lee thovislo esm for suchCan PCTlll Uccmic Lae( a hapten l
thatpriohe its licevaw0. RIM pursuant (Chapter
that he isscensed Puntion 7030) of lWConuacmr'and
Sq. Ft. Floor Area
Valuation
ProflAw
of Division Business onsCode) at
f
$
�0
so. Any
Nal Won exempt them(mm and the bub for 0e alleged esemptiw. Any violation of
that WoAcing xemit shecRome and basis fraflWegedcu
APN Number
Occupancy Type
Section 7031.3 by my applicant for A parmll subjnv the applicant As a civil Pointy of
not more than In hundred dollars (M).
34229028.00
❑ 1, As owner of the Property, ar my employee with wages As their Aide eompenadon,
RED Inspections
will do the work, and dile swclum Is not intended or offered for sale (Sec. 7041, Business
and Professions Cade: The Commune. License law does not apply in in owner of
101 - FOUNDA_ITP pd
property, who builds or Impwveathereon, and who dws.uch week himself wNmugh his
own employees, provided thalauch improvements art not Intended mortared (retain. If.
102 — PIERS
howawr, the Wilding ser improvement iasold within one year of mmpledon. the awler-
bullder. will have the buNen of proving that W did not Wild w Improve for purpose of
103 - UFER
sale')'
104 - REBAR
01,es owner of the property, am exclusively carmoming with licensed canuacmn to
105 - ANCHOR BOLTS
construct the project (Sec. 7044, Business and Pmfessiom Code:) The Commode's Lb
ave]taw does not appy w an owne, mf,mmsart, who Wilde or improves there., and,
106 — SEWER & WATER
enwclw(a)Iiwpursuant wWe CannactaYs
who L�cseLa.. .ouch pmjecu with ca
202 - UNDERFLOOR PLUMBING
ameaemptunder Sec. .B&PCfm lhs AWAm
203 - UNDERFLOOR MECHANICAL
r Data
204 - UNDERFLOOR FRAME
205 - UNDERFLOOR INSULATION
WORKERS COMPENSATION DECLARATION
I hemby a0lnn moiler peay lty of peduarc of the following declarelions:
301 — ROUGH PLUMBING
I hove and will maintain A CeniBate AfConscnt w selFlnaum fee WorkarsCampen-
an, v provided for by Section 37M of the Labor Dude, fee the performance of the
3 02 - TUB & OR SHOWER ,
k for which this permit is issued.
7371M
303 - ROUGH MECHANICAL
I haw and win maintain Workers Compensation Insurance, as required by Section3O4
— ROUGH ELECTRICAL
of the Lobar Cade, for the performance of the work fro which this permit b Issued.Workefa
Compensation Insurance anicr and Policy number art:
3O5 — FRAME
rver Policy No.:
306 - HOLDOWNS
CERTIFICATE OF EXFMP ION FROM WORKERS'
COMPENSATION INSURANCE
307 — INSULATION
Crib section need not WcampleledlflW Permit is fwane hundred doiw(slm)
308 — SHEETROCK
or Mss.)
309 - EXTERIOR LATH
I certify that In W pedarataKe or IW .ark for which thia permit his Issued. 1.nail not
employ any Person in my manwr An As m blame wblat to the Workers' Compensedw
310 — INTERIOR LATH
Laws of California. Date
311 - SCRATCH COAT
Appricam
313 - ROOF NAIL
NOTICE TO APPLICANT: If, after making this Cenincate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith
501 - FINAL ELECTRICAL ENERGY
comply win such p..mines ser this Permit shall the deemed rewkcd.
7
502 - FINAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY
I hereby affirm thsl were is a conswminn lending Agenry, for rte Performance of
503 — FINAL MECHANICAL ENERGY
i rte work for which thispemti Isissued (Sec.30)7,CIv.C.1
504 - FINAL BUILDING ENERGY
7 Lcndcrs Name
505 - FINAL ELECTRICAL
z Lender's Add.,
1 certify that I how read this application and sum that the .have information is
506 - GAS TEST
correct. I agree to comply win all city and county aNinances and sum laws mtsting in
building consuoclion, and bei Buthodm mpretenudws of this city m Amer upon the
FINAL PLUMBING
.hove-menuwed murcny for inspection Purposes.
08 FIN L
y (We) agree w save, indemnify and keep harmless the City of Cupertino against
n liabilities, judgments, costs and expense. which may In any way ..me against aid City
I
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:5 NG Date
SOURCE REGULATIONS.
_
Re -roofs
Type of Roof
SiSignatureofAppll _ or
HAZARD_OUS MATERIALS DISCLOSURE Dau
Will rte applicant or ruture W ilding occupant.wm ser handle bacafdaa mamnal
Med by rte CuperMa MunidIF. I Code. Chapter, 9.12. and the Hearn and Safely
. Section 255320Y!
All roofs shall be inspected to any roofing material being Installed.
Oyes ON.
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
it havardow air contaminants u defined by rte Bay Area Air Quality Management
all new materials for inspection.
inrim?
❑Ya ON.
I haw mad the harallovsmsterialsmquimmentsun@rChapter6.95of the Glifor-
nuHcaln&SafciyCode.Socd=25505.25533v 25334.1mdem tMifthe Wilding
Jots not currently have a tenant, nal II u my mspavlMliy in wary the atuper, or the
requirements which must the met prior wissuance ofaCcrtinaeofOccupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner
or awhoriacd agent Date