03090075/I
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CITY OF CUPEWFINO
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BUILDING DIVISION PERMIT
.���TC.�ONTRACTOR'INF,ORMATION-
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Bu1LDINC ADDRESS:
07r PASADENA All
TERRY BROWN, GEN CONTRACTO
ERMIT N003090075
OWNER'S NAME:
14510 BIG
BASIN WY
PERMIT ISSUE DATE
E'
(408) 868-1640
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that 1 am licensed under_ provisions of Chapter 9 (commencing
p
with Section 7") of Division 3 of the Business and Professions Code, and my license is
In me fame sad affect.
License Class Lic.It
BE}NANT-71 R MENT
,-... I
Data Cu sitar -_^t .-
ARCHITECTS P.CLARATION /
I understand my plain ¢hull k use n public amt d x\,4 x tj
i t
1
Licensed Pntfcuional -+!
DWNER.BUILDE!E ,1TI
1j
I hereby olRrm that 1 an exempt tk Conn r' eon Lar far t
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following reason. (Section 703 1. Busing C n 11.11m.,
--
'
which requires a permit m cnnswc0 cite' ,h, m pint any ewnum
prior in its issuance, also requires the applicant for such permit to Ole a sign'"sukmcnt
that he is licensed pursuant the previsions of NC Convector's License Taw lChep or
Sq. F[. Floor Area
Valuation
(commencing with Section 7000) of Division J of the Business and Professions Code) or
Not he Is exempt thcnfrom and the basis for the alleged exemption. Any violation of
35717043.00
APN Number
Occupancy Type
Section 7D31,5 by any applicant for a permit subjects the applicant to a civil family of
not more than Ove hundred dollars 35W).-
0 I, as owner of the propvly, or my employees with wages u their sale eompenullon,
d Inspections
Mil do the work end Ne awdurt is net intended or offendv
fode (SecBusiness14. Business
Com: The Contractors
and Prefeaxio s Liam Law dors not apply be an owner or
102
- PIERS
Property who buildsorimmovex thenon,and whodas such work himulforthroushhis
own employ=, provided that such improvements are not intended oroQered for ask. If.
103
— UFER
however, We building or improvement is old within one year of completion, the owner.
Wilder will have the burden of proving that he did not mild or improve for puma= of
104
— REBAR
sato.).
105
- ANCHOR BOLTS
Coth al licensed convulors m
❑ 1.st u t the p of the Sec. 7property,em cense andvely contracProfessions
conatmnt the project (Sec. 704", Oesincu and Profcuions Cade:) The Contractor's Li.
10 6
- SEWER & WATER
cove Law does eat apply to an be, of property, who Wilde or barrows thereat,and
202
- UNDERFLOOR PLUMBING
nsed pursuano Ne Contrutoea
who contracts for such projects with a contrumr(s) liceu
License Law.
203
- UNDERFLOOR MECHANICAL
Q lam cx��w°'de�rSec�. 8&PCfor Nis awn
d
204
- UNDERFLOOR FRAME
owner l///�C D.te Y o
WORKER'S OMPENSATIONDECLARATION
205
- UNDERFLOOR INSULATION
I hereby elErnt under Penalty of perjury one or the following declarations:
301
— ROUGH PLUMBING
an and will maintain a Cerificate of consent to self-insum for Worker's Compere-
302
— TUB & OR SHOWER
a, u provided for by Section 37W of the labor Code, for the performance of the
303
- ROUGH MECHANICAL
work for which this permit is issued.
304
- ROUGH ELECTRICAL
❑ 1 have end will maintain Worker's Compensation Insurance, u required by Section
3700 of do labor Code. for the performance of the work for which this Permit is issued
305
— FRAME
My WorkeM1 Cnmpevetion lnauraae extrier and Policy Work, are:
306
— HOLDOWNS
Carrier: Policy No.:
CERTIFICATE OF ER EM PTION FROM WORKERS'
307
— INSULATION
COMPENSATION INSURANCE
308
- SHEETROCK
(This section mad not W completed if be permit is for one hundred dollars($ I W)
309
- EXTERIOR LATH
Inters)
310
- INTERIOR LATH
employ certify Not er the performance of las work far which t to permit is issued, l shel l not
311
— SCRATCH COAT
Lawso California,
Laws of California. DateAppl
313
501
- ROOF NAIL
— FINAL ELECTRICAL ENERGY
NOTICE afterCon making this Exemption. you umulst
NOTICE TO APo of
Labor
became sea.,bject m the Workers Cor this previsions of the lad r Cnor you rear
the Workers previsions
rs
(arthwithamply with such provisionsw thio perms shoe kdecmce mvotce.
SO2
— FINAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY
503
- FINAL MECHANICAL ENERGY
I hereby effum that Nen is a construction lending agency for the performance of
the work (urwhich this permit is iuucd (See. 7097. Civ. C.)
Lender's Name
504
505
506
- FINAL BUILDING ENERGY
- FINAL ELECTRICAL
- GAS TEST
lender's Adarau
1 ratify Nat 1 have read this application and state that the above information is
507
- FINAL PLUMBING
cancel. I agree to comply with all city and county ordinances and state Iowa relmo, to
building construction, and hereby amharin representatives of this city to enter upon the
ahovomcmioned property for inspection purposes.
(We) agree to save, indemnify and keep humless the City of Cupertino against
09
FIN MEC CAL
FI
liabilities. judgments. cox, and expoves which may in any way aura against said City
in consequence of Ne of this
5
NG /
grvmmg permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: 5
C WORKS Date
5 REGULATIO
r"R a.l 15 '?Ao/'d3
Re -roofs
Type of Roof
Signature of ApplicanUCoruwIor Gatti
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant ser future building occupant atom or handle hararduua material
as coined by the Cupertino Municipal, Cade, Chapter 9.12, and the Health and Safety
Code, Section 255324), _ /
'$No
All roofs shall be
inspected prior to any roofing material being installed.
❑Yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant uuequipment ormviccswhich
hazardous air contaminan, as de0ncd by the Bay Area Air Quality Management
all new materials
for inspection.
,let? py
Cl Yes IF7 Fu
I have real the Wearduusmmentsis romin ren, under Chapter 6.95 of the Calif.,
'
allHealth & Sofrty Com, Sem.nd 25505, 25533 and 25534.1 understand that if the building
Joax nol cuton0y haws tenant, Not it is my responsibility to nodly the oocupenl of the
nqm whkhwhirhmastbc tpnorwiuuwceofaccwficamo(Occupant
7,7611
Signature of Applicant
Date
All roof coverings to be Class "B" or better
t6_0
Owner-., n; ".grin