02110138 CITY OF CUPERTINO ^,''
BUILDING DIVISION PERMITCONTRACTOR INFORMATION:r
BU1.pI0(2%7I@IsiN PORTAL AV JEFF & DENISE OLIVER PERMITNT)2110138
1
NF10FPE& DENISE OLIVER APPLICATTH1tyla 5YY2O02
PIIONE: SANITARY NO. ! CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�0C R LICEN19D CrIATRACTOR'§DECLARATION
F Ila that Its 16..bd under is ns ac ter 9(conasomen Job Description
with Secti Divisi o` ofthe Businessiud Prucaiiairlde and ry.BSrna.is BATHRM REMODEL p
F N Lice
]to
and effun. ,I
q Z Liccnu
Dahe ontacmr
AR I 'S DEC AT
iU
1 undersand my plans 1 used a pts i rc s
6p6V
u�LLG Liccnud Prnfcssinnal
OWNER-BUILDER DECLARATION
u�<� I hereby affirm Thal I am exempt from dm Contractor's Liccnu Ln nr $2000
�u.00 following mason.(S¢linn 7031.5,Bushoss and Professions Code:Any city or county
$C� which requires a permit to construct,alter,improve,demolish,or repair any structure
m prior In its issuance,also requites the applicant for such permit o file asigncd nctemem
q�qsZse
that he is licensed pursuant a the provisions ofthe Cantacmfs License lewp&'P,ur9 3 6f3.4�dA�.A10A Valuation
Pea (commencing with Section 7")of Division 3 of the Business and Professions Cow)or
Nat he is exempt Hamilton and the basis for the alleged exemption.Any violation of
Section 703 0 by any applicant fon permit subjects the applicant to a civil penally or PN-N Occupancy Type
notmoa Nen fire hundred dollaa($510). 102 — PIERS
Vas owner of Ne property,or my employees with wages as their role compensation,
will da the work.and the svucWm is not mended oroffered torsade(Sec.7044,Business ±133 UPER
and Professions Code:The Conumcrofs License Law does not apply m an owner of 104 - REBAR Required Inspections
pmpeny who huilda or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for=to.If. 105 — ANCHOR BOLTS
however,the building or improvement is sow within one year of completion,the owner. 1O6 — SEWER & WATER
Wilder will have doe burden of proving that he did not build or improve for purpore of
ale) 202 - UNDERFLOOR PLUMBING
D h as owner of the property,am exclusively contracting with licensed contractors to 2 03 - UNDERFLOOR MECHANICAL
conswct the project(Sec.7044,Business and Professions Code:)The ConRecmfs Li-
wine Law does not apply toanowner ofproperty who Wilds or improves nation,and, 204 — UNDERFLOOR FRAME
who contracts for such projects with a conlracmr(s)Iicened pursuant to the ContractorY
License Law. 205 - UNDERFLOOR INSULATION
D Iamexempt under Sec. 7� B&P for this oncon 301 - ROUGH PLUMBING
neA-VM52_d'�//l/ / Data I 302 - TUB & OR SHOWER
WORKER'S COMPRINSATIONDECLARATION 303 - ROUGH MECHANICAL
I hereby alarm must penalty of perjury ane of the following declarations: 304 — ROUGH ELECTRICAL
D I have and will maintain a Certificate of Consent to scl6insure for Workers Camper.
action,as provided for by Section 37W of the labor Code,for the performmce of the 305 - FRAME
work for which this permit is issued. 306 — HOLDOWNS+
D 1 have and will maintain Worker's Compensation Insurance,a required by Section 307 - INSULATION
370()of the Labor Code,for the Performance of to work for which this permit is issued.
My Worker's Compensation lnsurctoce carrier and Policy number aa: 308 — SHEETROCK
Carrie Policy No.: 309 - EXTERIOR LATH
CERTIFICATECOMPENSATION IINSURANCE ON FROM ORKERS' 310 — INTERIOR LATH
mossection need notbe completed ifthe permit is forma hundreddollan($i0d) 311 - SCRATCH- COAT
irlcsa) 313 - ROOF NAIL
I cenify thct in the perfomuram of the wask for which this Permit it issued.)shall am 501 - FINAL ELECTRICAL ENERGY
employ any peraon in any man fur aceto he come ah'ttuo the%olm rCompensation
Law¢nl Calif}�nia.Dae��-z�^+-•tr=g 502 - FINAL PLUMBING ENERGY
Applicant fRit �Lil• yid
NOTICE TO APPLICANT:If.after making this Cenifa:ee of Exemption,you should 503 - FINAL MECHANICAL ENERGY
beenme subject to the Worker's Compensation provisions of the Labor Code,you must 504 - FINAL BUILDING ENERGY
OO forthwith comply with such provisions or this permit shall be deemed evoked.
CONSTRUCTION LENDING AGENCY 505 - FINAL ELECTRICAL
F� Iherehynffirmnor them iaaconswctiontrading agency I...meprformanctof 506 - GAS TEST
E
P, the work ferwhich this permit istsmed(Sm.3(A7,Civ.C.) 507 - FINAL PLUMBING
fat Q Lcndcr's Name
j Z lend rsAdd.. 508 - FINAL MECHANICAL
U O 1 cenify that I have read this application and state that the above intonation is 509 - FINAL GRADE
C[.F. correct.l agree 10 comply with all city and county ordinances and sate lins"alcttngm 5 FINAL PLANNING
O building construction,and hereby authorim repssenmives of this city m enter apart the
clove mcndonedpropertyfor ins etion purposes.
' a (Wm agree to ave,indemnify and keep harmless the City of Cupertino against 14 FIN I C
AWORKS
y liabilities,judgments,coats and expenses which may in enywayacemc againnsaid Ctly
U z in consequence of the granting of this permit.
a"t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU ERF.GUI.ATIONS.
1dA� ,, 1__� Re-roofs
Sigmtme of ApplicanVCmnracmr - Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building u,cupant store or handle haammas material
az defined by the Cupertino Municipal Coda.Chapter 9.12.and the Health and Safety
e,Sermon 25532(a)1
❑tics �Nn 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
emit haardaus air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District? vl,
DYcs upa
I have mad the hnardous materials mquirements under Chapter 6,95 of the Califo>
nits Heolth&Sul'ety Code,Sections 25505,25533 and 25534.d understand thctifthe building
does not currently have a tenant that it is my responsibility to notify the occurrent of the
�. aqui cols wIt limon lw( r;nrm issuance of a eradicate of Occupancy. Signature of Applicant Date
Owner or autrunmd agent Data All roof coverings to be Class "B" or better