03040015 CITY OF CUPERTINO r y.�fj " r{ T +,
BUILDING DIVISION PERMIT ��ar'L+ Lp�! -"^ y *'3 -
BUILDINGADDRESS: JAMES MA PERMIT NO.03040015
R'S NAME: - 10420 ORANGE AVE " I '722/2003
MES MA
E: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
ipz LICENSED CONTRACTOR'S DECLARATION
C V 1 hereby affirm WI I am beamed under provisions of Chapter 9(commencing �' MY •+r
e with Sucthat7 ).f Division 3 of the Business and Professiusu Code.and my license is 4M� s1a��se•
in full force and effect
; Z Lim.accla s Lic.g ADD 515 SQ. FT.
Date Conuuur MAY 9, 0 7004
e1q-� ARCHITECTS DECLARATION
C$ 1 understand my plans shall M used as public mcords
)yU
s,0 Licensed Professional 93UIL.DING
OWNER-BUILDER DECLARATION
9I hereby affirm that I am exempt from the CommcmYs License Law for the
3 a O following moon.(Section 7031D,Business and Professions Code:Any city or county
tat)
$V which requires a permit to mnswct alter.improve,demolish,or repair any snowture
priorto its issuance.A.requinsthcapplicantforsuch penile fileasignedstamment
2�< thetMislice..dpursuantlolMpmvislomof Ne Contnctur's License Lsw(ChaPur9 Sq.Ft.Floor Area $15 Y�"Ion
(c
Z ommencing with Section 7000)of Division 3 of the Business and Professions Code)or YY
i $ Nat he u exempt therefrom and the buss for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects,the applicant to a civil penalty of 3 AMI NotolgC 0 0 Occupancy Type
not more Nan five hundred dollars(5500).
❑I,azowner of the property,or my cmploycp with waguazOseirtole mmpewtlan,
will do the work.lad theswcture isnot intended oroffemd Formic(Sm.7044,Business iul - FO j dInspections
and Professions Code:The Cmarretal License Law does not apply Or an owner of
Property who builds orireproves darson,andwho dms,smh work himselforthrough his 102 - PIERS
own employ..provided that such Improvements sure not lnundrA moRered for sale.If. 103 - UFER
however,the building or Improvement is told within one year of completion.the owne-
builder will Mve the burden of proving that he did not build or Improve for purpose of 104 - REBAR
ei1e.)' 105 - ANCHOR BOLTS
❑I.as owner of the property.am exclusively contracting with licensed contractors l0 10 6 - SEWER & WATER
construct me project(Sec.70",Business and Professions Code:)The Contrector'a Li-
moseLawdoesnotapplytoanownerofpropertywhoMildsorimprovrsthemon.and, 202 — UNDERFLOOR PLUMBING
who contracts,for such pmjecs with a contrutor(s)licensed pursuant to the Contractor's
LiaenaeLaw. 203 - UNDERFLOOR MECHANICAL
l am empla r
xeSec. ,BkPCfor this moon
se 204 - UNDERFLOOR FRAME
WORKER'S COMPENSATION DECLARONO 205 - UNDERFLOOR INSULATION
I emby;rrlrm under pmalty ofperjury one ofthe mumvingdeclamions: 301 - ROUGH PLUMBING
l have and will maintain a Certificate of Consent to self-insure for Worker's Compen. 302 — TUB & OR SHOWER
utlon,as provided for by Section 3]00 of the labor Code,for the performance of the 303 - ROUGH MECHANICAL
work for which this Permit is issued.
❑I have and will maintain Workers Compensation Insurance,as required by Section 304 - ROUGH ELECTRICAL
3]110 of the labor Code,for the performance of the work for which this permit is issued. 305 - FRAME
My Wmkds Compensation Insurance,carrier and Policy number we; 306 - HOLDOWNS
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' 307 - INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
(This section need not M completed if the permit Is Coy one hundred dollar($IW) 309 - EXTERIOR LATH
or less.)
I ceni(y that In the per(rinanee of the work for which this Permit is issued,I shall not 310 - INTERIOR LATH
employanypcom in ymanncr oaztoMmmesubjuUameWorkers''Comp muds n 311 - SCRATCH COAT
lawao fforma. am 313 - ROOF NAIL
Avpuc
N 0APPLICAf I.after making this CenifcateofExemption.you should 501 - FINAL ELECTRICAL ENERGY
broom.s,ubjmt to the W ;eh Compensation provisions of the labor Code,you must
.Jz foth.altnmplYwiths hprovisioazuthispermitshallMdeemedrevelled. 502 — FINAL PLUMBING ENERGY
? CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
(hereby eMr.mal mere is a construction lending agency for me perimmarm of 504 - FINAL BUILDING ENERGY
C4 D the wurkfor which this permit Isissued(Sm.3W7,Civ.C.) 505 - FINAL ELECTRICAL
[T] Q Lender's Name -
� z LndrsAdaaa 506 - GAS TEST
U O I cenify that 1 have mad this application and sure mat the shove mime au at is 507 - FINAL PLUMBING
correct I agree to comply with all city and county unit....and sus laws relating to
Ubuildingconswction.andherebyalbum<representativesofthiscitytoenteruponthe - FI&jWNG ICAL
{Ta .hove-mentioned property for inspection purposes.
W (We)agree to save,indemnify and keep harmless the City of Cupertino against 0 F I
fy rat liabilities, coats and expenses which may in any way accrue against avid City
z In consequence of the graining of this permit.APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: 5 WORKSDate '
SOURCE REG TIONS.
Re-roofs
gnu ( ppli=VConuamor Dam 6,03 OOF BATTENS
HAZARDOUS MATERIALS DISCLOSURE Type Of ROO 4 - ROOF IN-PROGRESS
Will the applicant orfmurc hoilJing mcup.nt uorc orM chvardous material
ac defined by the Cupenine Municipal Cade.Chapter 9.12,and the Health and Safety
•,Section 25532(a)7
C]Ya XNu All roofs shall be inspected prior to any roofing material being installed.
Will thc applicant or future building occupant use equipment ar devices which If a roof is installed without first obtaining an inspection,I agree to remove
11 hazardous air contaminants m defined by do Bay Area Air Quality Management all new materials for inspection.
ismm?
01 Ycs �(N.
a
I have mal the,c,Somus macnals 5533 requirements d5 4.1 u Chapter thatof the Cdifon
nus nalth&etcumefctyhawa ant,Oat it
myresp25534.1 understand thatifthe Milling
does not currently have a tenant Nat it u my respomibilily m. y the. .Pent of the
require which Ibe met pforlemonrmeofaCenifcauo c amy., Signature of Applicant Date
Or 2 0
0 onumorimd seem Dare All roof coverings to be Class"B" or better