03060105 CITY OF CUPEWrINO �s,g+ ' t
BUILDING DIVISION PERMIT :qCONTRACT.nR INFORMATION:
a�i,4°fi WY �bB .frrsv 0 R
BUILDING ADDRESS: PERMIT NO03060105
.R'S NAME: PERMITLSUE DATE
PHONE: SANITARY N0, CONTROL NO,
ARCHITECrIENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
t� 0 t� t�
�COOO LICENSED CONTRACTOR'S DECLARATION lob Description
x I hcmby affum that I am licensed under provisions of Chapter 9(commencing p
e< with Swtion]IX110 of Divixion7rf the Eusinesaand Profcuinm .&.and myliccnw is
in full fume aneffect.d
Lice
n C Lic.N_�e REVISION--IN HOUSE USE ONLY
�Fqc Daw Cont calor NO NEW PERMIT ISSUED, ORIG. 303040015
�aARCHM-Cr ECLARATION
rat
of Jm plansa Mu ea public rtcords
e \h G� erase m(c nnal
Oat E exempt DER DECLARATION
COOI matoo ,(Sero that 11. Burinfrom the Contractor's License Law for the
COO following recon.f5muun 703 1.5,Business and Professions Code:Any city nr county
5 m which myuis a•permit it)re mires the
elver,tmpmw,demnnit 1.ore sig art's atrunure
�<
that
poor in its ceased e,also pursuant to the tW applicant of forthe suchCon ractor m Glc Lice =Laved mammcm
xx thatmencing wit Pursuann 000)of Division
of the Contractors adolaw(ChapterCode)Or Sq.Ft. Floor Area Valuation $0
(coF$ that he s exempt
with therefrom
and the
Dlutetoo r the
the Magna
xemt on,Any vi Code)ser
Net he is aempt therefrom and the basis for Ne alleged exemption.Any violation of
Section]031.5 by any applicant for a permit subjects the applicant o a civil penalty of 39c8&87: arr-r00 Occupancy Type
not more than five hundred dollars($500).
❑1,u owner of the Property,or my employ.with wages u their sole compensation,
will do the wank.and the stnwtune isnot intended or offered for ale(Sm.7044,Business RR
and Prelusion Code:The Contncmrs License Law door not apply to an owner of 101 - FOUND Rea d Inspections
property who Wildsor improves thereon,and who cocauch work himulf or through Ma
own employee,provided that such improvements arc not intended oroRated(mule.If. 102 — PIERS
however,the building or improvement Is sold within one year of completion,the Owner.
builder will have the burden of proving that he did not build of improve for purpose of 103 — UFER
sale')' 104 - REBAR
❑I.as owner of the property.am exclusively contracting with licensed contractors to
mottruet the project(Sec.704.4,Business and Profusions CrdaO'Ibe Conuacar's Li. 105 — ANCHOR BOLTS
come Law does not apply to an owner of progeny who Wilds or improve runners,ad. 106 - SEWER & WATER
who contracts for such projects with a contrsetor(0 licensed pursuant to tlw Contractor's
License law. 202 - UNDERFLOOR PLUMBING
❑taro exempt under See. .B&PCfor this moon 203 - UNDERFLOOR MECHANICAL
D'JN�
204 - UNDERFLOOR FRAME
WORKER'S COMPENSATION OECI.aRA7f�
I hereby afina under penalty of perjury am of theafollowing dttivaeonst 205 - UNDERFLOOR INSULATION
❑I haw and will mainmina CeruGrneof Conwnuoul5lnsum for Workers Compen, 301 — ROUGH PLUMBING
anon,as provided fm by Section 37M of the labor Code,for the pedmmmc,of the 3 02 - TUB & OR .SHOWER
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insunaa,as required by Section 3 03 - ROUGH MECHANICAL
3700 of the Libor Code,for the performance or the work for which this Permit is issued. 304 — ROUGH ELECTRICAL
My Worker's Compensation lnsuonce carrier and Policy number art: 3 05 — FRAME
Gorier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' 306 — HGLDOWNS
COMPENSATION INSURANCE 307 — INSULATION .
(Thu section wed not be completed if ton permit fe for one hundred dollars IS IM) 308 - SHEETROCK
to loss.) 309 - EXTERIOR LATH
employ certify than er am in any neat of the work for which thto permit is issued.1 shall not
Lawsoanypfornia anymanner.aw bocoma subjwur the wrrkeri Compeaufon 310 — INTERIOR LATH
Laws of Data 311 - SCRATCH COAT
NOTICE TO APPLICANT:IL after making this Ccdificatc of Exemption,you should 313 - ROOF NAIL
become subject to the workers Cont rwwtion provisions of the Labor Code,ynu must
'Z romawith comply with each Provisions rr this Permit shall be deemed invoked. 501 — FINAL ELECTRICAL ENERGY
z0 CONSTRUCTION LENDING AGENCY 502 — FINAL PLUMBING ENERGY
f-'4 1herebyafionthatthemisaconstructionleadingagencyforumiciformanceof 503 - FINAL MECHANICAL ENERGY
ai> the work fur which this permit is bawd(Sec.31197.Civ.C.)
W�^q Under',Name 504 - FINAL BUILDING ENERGY
� Z LnJer'sAddr 505 - FINAL ELECTRICAL
U 0 1 certify Nat 1 haw mad this application and sou that the above information Is F 506 - GAS TEST
torten.l agree to comply with all city and county oNinances and auk laws relating to
0 C.) building construction,and hereby authorim mprewntadves of this city to enter upon the — FIN PLUMB G
N U ah.c.moutioned property for inspectton Follows. —
G. (We)agree to ave,indemnify and keep harmless the City of Cupmiw against O F I AL
rVI Iialoities,judgments,c and expenses which may to any way accma against aid City
V APPLI or quNTc t ERSnANDSthis
ANDr ILL COMPLY WITH ALL 770 -P01 T Issued by: ING Daj
SOUR E S. IN v ,(� O
I Re-roofs
Si awre Ap innV ant a or Dam
AZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the app icam or future building m<upmt store at handle haardous mewrial
defined by the Cupertino Municipal,Cude,Chapter 9.12,and the Health and Safety
Section 25572(x)?
C]Y. k. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
trail horardnm it contaminants as dcfincd by the Bay Arca Air Quality Management all new materials for inspection.
District? t
❑Yes on
IIt a ma mawriatsmy ' nu under ChaPwr6.95of the Glifrm
nix Heal &S ty 'au]SNI5,25 J-53 4k l undcrsundthvifVv:Wilding
it nut I, waw ant at it is apousihili m uour he,xwupane of the
myvircm ai an. maeea� .Ceara cemtficaw or Occup.cr Signature of Applicant Date
o ar ser uthrelxed npen Dow /� All roof coverings to be Class"B" or better