03080044 COPY OF CUPERTINOy -0 - H t €
BUILDING DIVISION PERMIT CONTRACTMINFORMATION
"Mi
BUILDING ADDRESS: PERMIT N(03080044
.R'S NAME: PERMIT ISSUE DATE
JOHN TONG 3
NE: SANITARY NO. CONTROL NO,
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t� = 0
±00 LICENSED CONTRACTOR'S DECLARATION
I hereby tram that 1 am lianated under provisions of Chapmr 9(commencing Job Description
? with Scclie )ofDivision]of the Business and Professions Cede.aad my license is
N inrallram arfem- REVISION--IN HOUSE USE ONLY
)�? LiccnmC Lic.N
o Dam Con ctor NO NEW PERMIT, ORIG. #03050061
ARCHITECTS DECLARATION
I boa a 1 understand my plans shall he used as public rom ds
)yU
,eon Liccnmd Professional
OWNER-BUILDER DECLARATION
aS 1 botchy affirm that 1 am exempt from the Contractor's License Law for the
-00 rullowing Mason.(Section 703 1.5,Business and Proressinns Code:Any city or county
�$ which myuils a permit to construct.titer,impmva.&..fish.n1 repair any structure
-Z} prorlo its iaNanm.also no,tieas the applicant forauch Permitto Ele a signed Statement
O that he is licensed promorin the provisions of the Contractor'sContractor'sLicense Law(Chapter 9 Sq.Ft. Floor Area ValuatiC$)107
a+F (commencing with Section WasE of Division 5 of the Business and professions Code)or
d°
that he is exempt Ihcrcfrom and Bre basis 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 W1241dinSer0 0 Occupancy Type
not more than five hundred dol las($500).
1,as owner of the pmpcny,or my amployca with wages as Noir mic com pensallon,
will do the work,and the structure is at intended or offered for Win(See.70,14.Business gg d Inspections
and Professions Cade:The Contractor's License law does not apply to an owner of 101 - FOUNDA' ( M p
property who builds o improves lheceon,and who Eoesauch work himself orNmugh his
ownemployces,provided that suchimpmvements amnol intended oroRered recruit.If. 102 — PIERS
however.the building or improvement is mid within one year of completion,the owner.
builder will have the burden of proving Nat he did not Wild or improve for purpose of 10 3 - UFER
sale') 104 - REBAR
6 1,as owner of the ploperty,am exclusively convecting with licensed convenors to 10 5 — ANCHOR BOLTS
construct the project(Sec.7044,Business and Professions Code:)The Cr comer's Lt
come law does not apply to an Owner of property who Wilds of lmpruvm thereon, oil, 106 — SEWER & WATER
who contracts for such pmjcca with a contractorppursuant)licensed pursuano the Contractors
LicenaeLew. 202 - UNDERFLOOR PLUMBING
❑ I am exempt under See. B&PC for this mason 203 - UNDERFLOOR MECHANICAL _
ATION DECLARATION at 204 - UNDERFLOOR FRAME
MP
Ihereby arBmunder PenahyofperjuryMae ofthe following declarations: 205 - UNDERFLOOR INSULATION
Ihave and will maintain aCertificate nfcnmentmaalr-immmferwarkersCempen. 301 - ROUGH PLUMBING
action,as provided for by Section 37M of the labor Code,for the Performance of the 302 - TUB & OR SHOWER
work far which Box Permit isissred. 303 - ROUGH MECHANICAL
Fl 1 have and will maintain Workers Compensation Insurance,a romped by Section
3700 of the labor Code,for the performance or the work for which this .if is issued. 304 — ROUGH ELECTRICAL
My Wokors Cam pemation lnsusnce carrier and Policy number am: _ 305 — FRAME
Came° Policy No.: 306' - HOLDOWNS
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 307 - INSULATION
milarectiao need not becomplood iflhc permltisforonchundrctlinlials($Hip) 308 - SHEETROCK
,,IC9..) 309 - EXTERIOR LATH
1 ccnify Nat in the performance of the work for which this permit is issued,1 shall not 310 - INTERIOR LATH
employ any P rmn in any teacher an u w become subject to Me Worlims Comnt
pealion
Laws of California.Dem
Applicam 311 - SCRATCH COAT
NOTICE TO APPLICANT:If.after making this COO!reave of Exemption,you should 313 — ROOF NAIL
become subject to the Worker'sCompcmetion provisions of the labor Cndc,you must
.J z ronhwith comply with such Provisions or this Permit than be deemed revoked. 501 — FINAL ELECTRICAL ENERGY
Z� CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
I herehy alarm Boa,Nem is.construction lending agency for me Performance of 503 - FINAL MECHANICAL ENERGY
0. 0 the walkrorwhmnlhap.it isissued(saa3N7.civ.c.)
Under's Name
504 - FINAL BUILDING ENERGY[
ft1
a Lenders Address 505 - , FINAL ELECTRICAL
U O I minify Net I have mW this application and slam that the above information is 506 — GAS TEST
ty (•" comm.1 agree to comply with all city and county ordinances and sum laws relating to
�U building construction,and hem by amortize mprcmmadvas or this city to enter upon the FIN PLUMBING
W above-mentioned properly for inspection purposes. 08 F I&arNG
L
G (We)agree to sue.indemnify and keep harmless the City of Cupcnino against
N liabilities,judgments,costs and at,coneswhich may inany way see=against said City 5
U Z in eonamosimee or the&...ting of this permil. ///
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:5 Date I /
SOURCEREGULATIO S, _
Re-roofs
Lure Applic m Unity
HAZ GUS MAT CLOSURE Type of Roof
Will the applicant ser fuwre WIIJing eccupam norc or hemllc harallous memrial
J-,,d&,.cIincd by 1M Cupenim Municipal Code.Chapmr 9.13,and the Health and Safety
sacllea sssu(e)? Allroofs shall be inspected prior to any roofing material being installed.
❑Ycs NuWill the applicant f bud'in'occupantusecyuipmem or devices which If a roof is installed without first obtaining an inspection,I agree to remove
ha andous air conmmi as dammed by he Bay Arca Air Quality Management all new materials for inspection.
Q Vcs ❑NO
1 have mad Nra
e hardousrs¢rialsmyuimmems under Chapmr6.95 of the Califor-
niaHealth&Safety Cede,Smomas 25505,25533 and25534,1understand then fthe Wilding
docs not cu rally have a mnant,that As my rcapmnsihility m mmoy the Occupant of the
myuircmenu Aichmslbemclptlor iuumccofaCcrtiOnmo(Occ e. Signature ofApplieant Date
�f�d
.11
"bivnerm-ountliGoolfaiuc All roof coverings to be Class"B" or better