03090038 CITY OF CUPERTINO ' ' �` - ' '` '� '?'-TR"
BUILDING DlvlsloN PERMIT CONTRACT INFORMAT—f N
au1LDlNC ADDRESS: CAROLYN MILLER/BERT FRESCU PERMIr"D03090038
N ME: PERMIT ISSUE DATE
/04/2002
NE: SANITARY 0. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
X00 LICENSED CONTRACTOR'S DECLARATION Job Description
F"+F T hereby affirm that I•m licensed under provutions or Chapter 9(commencing p
Z wish Section 7")of Division 3 of NC Business end Professions Code,and my license is �e
<< a full force and effect.
License Claes CLic.onn ADDITION/REMODEL PATIO
s= Data
Connector
££ ARCHrIECI'S DECLARATION
I W< I undc.chnd my plans atoll be used u public...,its •�`
)6U
C0 Licensed Pmfcuionel J
�y Oat I Am exempt
from
DECLARATION /
0 1 Wnchyroma .(Sete on 71 1. exempt from ths Contractor's Co License Law for my q \
00 whfollich
roman.a Perrot in In LS,B.star,ins d improve,
de Poli h.or:Any tiny or county l �s
5$(v which myuircu a issuance,al.m aim.the ahaa improve,demolish, fie.iir any warmat V
�y thatheor ichensedpalmmyuimuhovisiosor for$Ochpermi'toicense Law(Charter
ss< nhbthcislicensedpursuantnuhcpmvisiovnfthe ConwnoreLiLenacLew(Chaplcr9 Sq.F[. Floor Area Valu hon
e 5 Frs (commencing with Section 7000)of Division 3 of the Business and ProRuionz Code)or 'i9.riRn41 00
3 that M la exempt Ihctefrom and the buss for don alleged eaemplion.Any vialadon of
Section 7033,5 by a"applicant for apermit subjeechmi applicant-to a civil pevhy of APN Number Occupancy Type.
not mon than fin hundred della.($500). - -- " - - -
❑I.as owner of the property,or my employees with wages As Inch sole compensation,
will do the work and the,smuc[am is Aid ntended or offered for sale(Sec.7W,Business 101
And - FOUND A } d Inspections
and Professions Code:The Conctor's License Law doss nm apply to an owner of
property who builds or Improves memo mil who does such work himselforthrough his 102 - PIERS
own employees,provided that uch impfonmenu sae not amnded or offered(mule,If. 103 - IJFER
however,the building or improvement Is sold within one year of completion.the owner
builder will have the burden of proving that he did not build or Improve for purpose of 104 - REBAR
A
.).
.a owner9S=fion
roperty,am exclusively ZU�Code,
g with licensed cemnMrs m 105 - ANCHOR BOLTS
mutt the pec.7Ma.Bmiaea and CWc:)The Commences Li. 106 - SEWER & WATER
e Law doely to an owner of propeilds or improves thereon.and, 202 - UNDERFLOOR PLUMBING
common; projects with a cdnnraemd pursuant to the Contncrofa
"" 203 - UNDERFLOOR MECHANICAL
pec. B&P C r m on9204 - UNDERFLOOR FRAME
E 'S COMPNSA ARATio 205...: UNDERFLOOR INSULATION-
Iherebunderpenatyorperju followingdeeleratiov: 301 . - ROUGH . PLUMBING
ban and chia•CCrtmale Of con6imum forWorkeh Compen. 302 - TUB & OR SHOWER
u provby Section 3700 of the e,fes thin performance or de 303 - ROUGH MECHANICAL
work rot which this permit is iaued.
❑I haw and will maintain Worker's Compensation Insurance,As required by Section 304 - ROUGH ELECTRICAL
7700 of the Labor Code,for Ne pfforramcn of the work for which this Permit is issued.
My Worker'.Compensation Insurance 305 FRAME
carrier bad Policy number am: 305 - FRAMEHOLDONS
Carrier: Policy No.:
CERTIFICATE OF EKEMPITON FROM WORKERS' 307 - INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
or kss)mailmailAssuan teed not An completed It[be Permit is for ane functional dmlan($IBD) 309 - EXTERIOR LATH
1 unify that in me performance of the work for which this permit is isseed,I shall not 3 10. INTERIOR LATH
employ any peon in any manner an u w become subject to the Wmrkan'Compensation 311' - SCRATCH COAT
Laws of Celifmnia.Date
Appllean 313 - ROOF NAIL
NOTICE TO APPLICANT-.If,after making this GCNficale of P.xemption,you should 501' - FINAL ELECTRICAL ENERGY
became$Object a the Workers Coinpcnunion provisions of the Lehrer Code,you must
�0 forthwith comply with such provisions or this permit shallbe deemed mvokcd. 502 - FINAL PLUMBING ENERGY
�y CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
I bemby affirm that mem is a construction lending agency for the performance or 504 - FINAL BUILDING ENERGY
Y
in work for which thu permit h issued(See.3097,Civ.C.)
incl
Leader's Name 505 - FINAL ELECTRICAL
>z ender1Addma 506 - GAS TEST
J Q I certify mai have recd this application and sum that the shove m misting is
wildingIagrcewcomply
,Andhi@alcity and caumyominstaesand sumnenterupingm 507 - FINAL PLUMBING
^,U abovengconswctiogadherchyaumonpurposnenutivaufmiucitymennerupnnlnO FIN MEC CAL
abovemenlioned properly forinteractionAnpurposes /
rG ( •greetecave,Indemnifyadkith may
theyscnCupertinoid Citl O9 FI
y (q Iiabil ,Judgmsnch.com sad apeves which req in ay way accroe against old City
J z in uence of the gaming of ini rmie 5 NG
I ANT UNDERSTAND WILL COMPLY WITH ALL N- INT Issued by:5 C WORKS Date
EG N5.
Q 3 Re-roofs
igsnwm OfApplicmInContionnor Gain.
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future wilding occupant store in handle hanrdous material
As defined by the Cupertino Municipal Cade,aspect 9.12,and the Healm and Safety
sjMde.Scmion 2553:(.)?
❑Yu ®N`/o All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Id.,
havamnv air conchminams u darned by the Bay Area Air Quality Management all new materials for inspection.
rot? /
❑Yes OBN.
I have mal the hmamnus materials mquimmena under Chaperb.95 of me Califor.
lt acty Cadc,Secdons25505, SS33ad2553q,1u"dcnwdmaifthewilding
n only Aow a tenenn,mat i rcupovihiliny m naul'y the Occup of c
m was m t mesh' w cc or. nonce ofoccup.9gy� Signature of Applicant Date
mermadmariacd seg m l7�D, All roof coverings to be Class"B"or better