03100020 CITY OF CUPERTINO
BUILDING DIVISIONPERMIT ,!C NTRACTORINFORM&IO,Nt -
BUILDING ADDRESS: HIGHLAND CONSTRUCTION AND Lal[Np03100020
OWNER'S NAME: 20073 NORTHCREST SQ PERMIT ISSUE DATE
9'19
ONE: 4082411858 SANITARY NO. CONTROL N0.
ARCHITLCTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MPH
;Oo Lthat
DCONTRACnderp DECLARATION Job Description
i¢C I hereby affirm Ihot 1 am licensed under and
Professions
ofChapterCode, 9(commencing P
with Section]IXN))n(pivision3of the Buainusand Prrfesainns COdc,and my license is
.<� pmnmrlass y BATHROOM REMODEL/WATER HEATER &ISS
a�Z License Clws �� Lic.M
t- Date �' COnlmctor WINDOWS/FU� // '
q ARCH CTS DGCLAA!1 A 1 M�9
U (understand my plans shall be used as p6lflle ren d/
,o1 Licensed Professional MAY 1 0 2004
g OWNER-BUILDER exempt
DECLARATION
0 0 hcrchy affirm that 11. cBusin from the Contractor's o e:enseAny c Lew co the
aOD following reason.(S)cuut 1onstr Business and improve.
demolish,
Code:Any city or county
5$� which myuircs a permit m uinisda,aline impure,demolish,erre pair any statemeAxIsalnt,iy triton its issuance,Olsnal.10 the thcappneant forsuch rmitmicense Law
(Chapter
z< that he(commescing wit punuant loth)ofponvisions or sion3f aBusinessContractor's License Law(Chopmr9 Sq.Ft.Floor VaIU®[ OOO .
ZF� (cat he IS
(commencing Seaion]IandouDivision3"fthc ed Business and ProfessionsCode)or
Y
� that he Is exempt Ucrtfrom end Ue basis for the alleged exemption.Any violation of M.i�. .A,
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 33'&'BI-qt"Qr0O Occupancy Type
not more than five hundred dollars($500). P Y YP
❑1,as owner Of the propeny,or my employees with wages as their sole compensation,
will do But work,and the SWeture is not intended oroff..d for Sale(Sec.7094,Business
and Profusions Code:The Conwclori License law does not apply to an owner of Required Inspections
proMny who builds or improves thereon,and who deessuch work himulfor through his 101 - FOUNDATION
own employees,provided that such improvements arc not intended proffered foreale.If, lO2 — PIERShowever,0e building or improvement is sold within one year of completion,the owner
builder will have the burden of proving that he did not build or improve for purpose,Of 103 - UFER
E'") 104 - REBAR
❑s u owner of project
property,,Business exclusively contracting with:)Tic d eonuanors m
come La the"notapplyJo nOwneofpro, Professionsds or i Thees daemon,
Li- 105 — ANCHOR BOLTS
cense Law do"not
such plyman with
o(propeny who
ce licensed pursuant
Centra.and, 106 — SEWER & WATER
who contracts far such projects with a crnmacmr(s)liccnud pursuant to dm Contractors
Larose Law.
l 202 - UNDERFLOOR PLUMBING
❑ am
exempt under Sec. ,B&PCfor this reason
203 - UNDERFLOOR MECHANICAL
Owner Date
WORKER'S COMPENSATION DECLARATION 204 — UNDERFLOOR FRAME
I hereby affirm under penalty of perjury one of the following declarations: 205 — UNDERFLOOR INSULATION
C l have and will maintain a Ceniecam of Consent to self-insole for Worker's Compcn- 301 — ROUGH PLUMBING
urian,ke provided for by Section 37110 of for Tabor Code,for the performance of the 3 02 — TUB & OR SHOWER
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Suction
303 - ROUGH MECHANICAL
3700olthe labor Code,far the perfarmancc of rrk for which this pcnno is issued. 304 — ROUGH ELECTRICAL
My Worker' m ani Ins ecanicn rimy number� �,a305 - FRAME
Carrier: [icy No.: rG
CERTIFICATE OF EXEMPTION FROM WORKERS' 306 — HOLDOWNS
COMPENSATION INSURANCE 307 - INSULATION
(This union need not he completed it the permit is or hundred dollars(I IW) 308 - SHEETROCK
or Icas.)
1 ccnify but in the performance of the work for which this permit is issued,[Shan not 3 09 — EXTERIOR LATH
employ any person in any manner an as in become subject a the Workeri Compensation 310 — INTERIOR LATH
Laws of California.Dem
Applicant 311 - SCRATCH COAT
NOTICE TO APPLICANT:If,after making this Carprcatc of Exemption,you should 313 - ROOF NAIL
become subject to the Worker's Compe notion provisions of the labor Code,you must
]O forthwith comply with such provisions or this permh shall W deemed marked. 501 — FINAL ELECTRICAL ENERGY
CONSTRU MON LENDING AGENCY 502 - FINAL PLUMBING ENERGY
re
I hereby affirm that theis a croatruclion lending agency for the perfurmance of 503 - FINAL MECHANICAL ENERGY
> U tiworker's or which this pmmitisisSued(Sec.39],Ci¢C.) 504 - FINAL BUILDING ENERGY
I]Q Lender's Namc
L Lceder'a Address
�Z 505 - FINAL ELECTRICAL
.J 0 I certify that 1 have read this city
an coup and Smte that the abrin information mis ting[s
y buildingIagreetocomply with ycityandcountynNtivesorand atomlawsreprime 506 — GAS TEST
DU building construction,and hereby awhor[re representatives of this city to cnmrup.n the FIN PLUMB G
ahovomenrloned property for inspection vo wses.
r (We)agree to save,indemnify and keep harmless the City of Cupertino against FI L /
rn
liabilities,judgments.costa and expenses which may in any way ace against said City 5%
G 3'
J `Z in consequence of the grainier (this permit
^ APPLICANT U 5 SAND WIL HALL NON-POINT $$U by: ING Date
SOURCE R T s: / �' 514 NAL PUBLIC WORKS /
e-roofs
Signature Of ApplicanUComraew, //� Dam
HAZARDOUS�6A`fERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant score or handle haoddmw m ria"
as defined by the Cupertino Man,, al Code.Chapter 9.12.and the Health an afety
Code.Section 25532(.)? ? All roofs shall be inspected prior to any roofing material being installed.
❑Yes rNJu
t 7If a roof is installed without first obtaining an inspection,I agree to remove
JP
Will tM applicant or!marc building occupant use equipment or devices which
haurdoi s air converto )fined by the Bay Arca Air Quality Management all new materials for inspection.
Disola?
[I Yes ❑No - -
I have mad the h"sNnusmamrials reyuircments under Chepmr6.95 of thd Calif.,
nia Health&SdetyC dc,Sceuons 255fs5,25533 and25534.1 undcrsmnd distill building
does not currently have a mount,that it is my REponsihility to notify the occupant of the
myvircmc yat/�'y,Qt�err o, r.Ccmficamof«)non _ IgnatureofApplicant Date
- �
Owng
All roof coverings to be Class"B"or better
er tar authorize)sgenl Dam cover