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03090152CITY OF CUPEwrINO BUILDING DIVISION - PERMIT %CONTRACTOR INF0RMATI0N >a�Y3nT 80*.�' ?iii+tee `i�Luv. ix'Yeli�' BUILDING ADDRESS: PERMIT NO03090152 3090152 OW NER'S NAME: `17FRnNT(­A TAM PERMIT ISSUE DATE 9/2 ni NE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLOC ELECT PLUMB MECH C� 0 LICENSED CONnRSDECLARATION I lob Description underder provisions of Chapter 9 (commencing I hereby affirm that am litteredd mi P With Scniof Division ]of theBminess and Profcuion. Code, and .1 license is in full fo la andndeffect. effect. (once Licenx Clam Lica DEMO (E) POOL Data Contractor ARCHITECTS DECLARATION I understand my plans shall be used as public records SEP 2 4 2003 Licensed Pmfcmuoml OWNER -BUILDER DECLARATION 1 hereby affirm that Iam exempt from the Contractor's License Law for the BUILDING following mason. (Section 711]1.5, Business and Pmfessiom Code: Any city or county which ox irra a Permit m eonammi. alma improve, demalLvh, or mpair any structure Prior us its issuance, also requimvhe applicant forsuch Permit to file a signed statement that he is licensed pursuant to the pmvisionsofthe Contractor's License Law (Chapter 9 Sq. Ft. Floor Area Valuation (commencingwith Section 7880) of Division ] of the Business and Promasions Code) or Inn he is exempt therefrom and the basis for the alleged exemption. Any violation of 31635004.00 _ _ .. -.. APN Number Occupancy C_. P y T'P Section 7031.5 by any applicant fora Permit subjects the applicant to a civil Penalty lir - _ .._ __ .... not more man five hundred dollar. (SS00).' ...- _ ❑ 1, as owner of the property, in my employees with wages as their sole compensation, Required Inspections will do the work, and the structure is not intended or offered r ... In(Sec. RMS, Busi neo— and Professions Cade: The Contractor. Lin" , law does nut apply to an owner of e Q ns p property who builds or improves demon. and whodoes such work himselfor through his own employers, provided that such improvements me not intended or offered for sale. It. hawewq Ne building or improvement is sold within one year of completion, the owner builder will have the human of proving that he did not Wild or improve for purpose of sal .). 1, as owner of Ne property, am exclusively contracting with licensed convectors to cc over the reject (Sec. 700x, Business and ofmiam Cade:) The Ct nuaceiri U. cerise Lawd not apply to an owner of prop y ho builds air improves menton, and woo conuac for such prgeeb with aeontrxm li nxd purauanuo the Contractor's License Law. ❑lam eaemt oder See ,B&P this r� 17 �n , -- ORKER'SCOMP NSATIONDECLJR TION I hereby affirm under Penalty of perjury one of the following declarations: I have and will maintain a Certificate of C4.eal to relf-inxm for Worker's Compere ration,. provided for by Section 3700 of the labor Code, for me performance of the work for which this permit is issued. - ❑ 1 have and will maintain Workers Compensation Insurance, es required by Section 37W of the labor Code. for the performance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Policy number sm: Cartier: Policy Ne.: _ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section tetrad nm hecomplemd Rate Permit a fm enc hundred dollars n If1() lir less.) 1 cenify that in the performance, of the work for which this Permit u issued, I shell not employ any person in any manner sat as w become subject o the Workeri Compammilon Law. .(California Dam Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Worker's Compensation previsions of the Labor Cade, you must forthwith comply with such provisions or this Permit shall be deemed minima. , CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agenry, for 1M performance of the work for which this permit Is issued (Sec. 3097, Civ. C.) Lender's Name Lender's Add., I cenify Ino I have read this application and SUM that the above information is correct. 1 agree to comply with all city and county ordinances and same laws relating to building Conswction, and hereby aumorix representatives of this city to enter upon the above-mentioned property for inspection purposes.. (We,) agree eco save, indemnify and keep harmless the City of Cupcnino.g111.1 liabilities,] gmcnu,c.a.nd.pcnwhich may in any way atenagainst mid City in eonuq. cc of dam ming w x of this / gm permit. APPLICA OERSTANDS AND WILL PLY WITH AP INT Issued by: Date SOURCE R LATIONB. Re -roofs Si azure of p m nV ser mr 1 1 Data HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupmutom or handle haramons material u defined by me Cupertino Municipal Code, Chapter 9.12. and the Health and Safety code. Ormexss]2(a)? All roofs shall be inspected to any roofing material being installed. j$N. prior If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building Occupant tau equipment or devices which ,t hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. Ohm? ❑Yes '�QJo Ir. a mad th,hvaNnd/sm .Ismyvimmcnu un der Chapter 6.95 of the Califon ria Health Samlycode,Seetom25w ]]and 255]0.1um MdmWthmifdCWilding does not c n y have a mnanL Not it' y responsibility m no upset of the Bq men is must N met priors issuance or. Centric= c c Signature of Applicant Date o 3 All roof coverings to be Class "B" or better bwnmr ar ant rnima .sem Date r J�• (WIT CUPERTINO CITY OF CUPERTINO DEMO PERMIT APPLICATION FORM b3o76/s q� APN # /S"J) BUILIDNG Date: �} / % /03 Buildin Address BSEISMICOM Own is N :I BUILIDNG —e Phone #: /�D Contractor: / BSEISMICRE Seismic Residential BUILIDNG License #: Contact: BPLANCHK Phone #: Applicant/Contractor: ildipg Permit Info: (Bldg,/ Elect,—> (Plumberech b5 'Description: Residential: Ce } Commercial: Sq.Ft. Floor Area: $/Sq.Ft.: Architect/Engineer: ValuatiKnlej Type of Construction: Occupancy Gra p: rA Qty. if Anol able i Fee ID Fee Descrintion Fee Groun f BPERMFEE Bldg Permit Fees BUILIDNG BSEISMICOM Seismic Commercial BUILIDNG —e / BSEISMICRE Seismic Residential BUILIDNG BPLANCHK Plan Check Fee BUILIDNG BUSLIC Business License BUILIDNG