03070067 C[TY OF CUPERTINO
r G3 +
'1';'n PRIWERIDGE AVE
BUILDING DIVISION PERMIT CONTRACTOR INk'ORMATION::
«�R AT
BUILDINGADDRESS: PERMITN003070067
OWNER'S NAME: PERMIT ISSUE DATE
E: SANDARYNO. CONTItDUNG.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BO ELECT PLO MEC"
j00 LICENSED CONTRACTOR'S DECLARATION MJobDescri Description
M(y 1 hereby affulitt
m that 1 am nsed ucomen
under provision,of Chapter 9( mcing p
n?j with Section 7IXXgnf Dwi,lin Sof the Rotors and Prufcasinm Cnde,wd my license i,
m fall race sad effect' TI-2MSWi&Y MODELING &
Lj? License Clan Lm.«
DsuiCcnomcuu EXTIOR RATO DEVELOPM
ARCHITECTS DECLARATION
I undcmmud my plan.shot[M usedo,public rccards s
p u14
50 dProfcuional
OWNER-BUILDER DECLARATION
1 botchy Alarm that 14M exempt from the Contractors License Law for the
0U following mason.(Section AD 1.5,Business and Professions Code:Any city or county 7
3 g on which rcyuire,a permit to construct,tlm
mr.improve,demolish,or.pair any mrwow _
_ ED]
Prior tit its iuuonce,also.yvi.s the applicant for such Permit to rile a signed,utement
r< that he i,licensed pursuant the provisions of the Contractor's License lzw(ChaPler9 Sq. Ft. Floor Area Va�ijtbio000
S (commencing with Section 7CM)of Division 3 of the Business and Profeaions Code)or
— that he ts emmpt therefrom and the basis for the alleged eaempuon.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to civil penalty of 314`131e4fterO 0 Occupancy Type
not more than firs hundred dollars(5500).
1,a owner of the property,or my employees with wage as their sole wmpenution. do
e
will do the work and Ne,tmctute is not intended or offered for sale(Sec.7061,Business Re hired Ins ectlOn �«f/�
�a
and Predicate..Code:The Committees Lt..Low does Wt apply w an owner of p vlL
property who build,or improve,themon,and who dmaauch work himselfor through his 101 - FOUNDATEON Y/
own employees,provided that such improvements are not in.nded oroffe.d *
formic.If, 102 — PIERS .
however,the building or improvement is sold within one year of completion.Ne owner. �/
builder will have the burden of proving Nat he did not build or improv for purpose of 103 — UFER 7 O/
yl`')' 104 - REBAR
h a owner pis the property.am exclusively contracting with licensed contramrs to ✓ / d
coo met the project(Sec.7044.Business and limitations Code:)The Contractue,Lt. 105 — ANCHOR BOLTS. �V o
mom low does oot.pply.....a,of rapany whe build.or improves theater,and, 106 — SEWER & WATER .
who mm scot for such projects with a contrutor(q licensed moment to the Contactor,
Lice
arm Law 202 - UNDERFLOOR PLUMBING
❑la nderSec. ,BAsPCfar thtamsson 203 - UNDERFLOOR MECHANICAL
0 KE 'S COMPENSATION DECLARATION 7 1ii� Dow -u� 2 04 - UNDERFLOOR FRAME
I by slim under penslly at perjury am of the following declarations: 205 — UNDERFLOOR INSULATION
haw and will maintain a Certificate of Cement self-insure for Worteri Compen- 301 — ROUGH PLUMBING
atom,m provided for by Section 3700 of the Inbar Code,for the performance of the 302 — TUB & OR SHOWER
work for which this permit is issued. 303 - ROUGH MECHANICAL
❑1 haw and will maintain Wortrra Comparandr t Iruuana.a required by Section
31MofmaLaborCode.for the performanceofdwworks for wMehthis permit isissued. 304 - ROUGH ELECTRICAL
My Workers Compensation Insurance carrier and Policy number em: 305 — FRAME
Car"`n P`li`yNo" 306 - HOLDOWNS
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 307 - INSULATION
(Thi,section need not W completed if the permit is for one hundred dollars($100) 308 — SHEETROCK
Irma') 309 - EXTERIOR LATH
employ Nn in the in anyo rte If the work for cube Nis permit rllaced,Ishall raw
employ any mourn in mymannerslall become subject theworkeri Compcnation 310 — INTERIOR LATH
Laws of California.Dew 311 - SCRATCH COAT
Applicant
NOTICE TO APPLICANT:It.after making this Ceniftcam of Eachiption,you shoulti 313 - ROOF NAIL
become subject to the Workers Con,ctuauon provisions of the LaWr Code,you most
Z forthwith comply with such provisions or this Permit shot]W deemed revoked. 501 — FINAL ELECTRICAL ENERGY
Z O CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
1he.hyaflirm Nat thea is a counteraction lending agency for the Performance of 503 - FINAL MECHANICAL ENERGY
x� the work fur which this permit is issued(Sm.3041,Civ.C.)
Lender's Name 504 - FINAL BUILDING ENERGY
W Q
Z) Lenders Md..
�z 505 - FINAL ELECTRICAL
o I certify that I haw rad thisapplication and Uses that the,above information is 506 - GAS TEST
W f~' collect.l agree to comply with all city and county on inaaen and slow law,Gating to
0 U building convection,and hereby authorise representatives if this city to enter upon the FIN PLUMB G
�+0. above (WO)
pmpeny for inspection porpoises.
(We)agree to save,indemnify and keep homeless the City err Cupertino against 0 8 F I L
Tq lonikus,judgmcnu,costs and expense,which may in any way acme against aid City 5
U z in canmltinwo lin granting of Ni,permit. U �/y
" APPLICA N RSTANDS W L COMPLY WITH ALL NON-POINT Issued by:5S ING Date
SOURCE U 0
-o Re-roofs
a fApplteaHAZARDOUS MATERIALS DISCLOSURE Dam Type of Roof
all the applicant or future Wilding occupant arm or handle hatmeoa material
as dented by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(.)/ '_'a"5/'a,,,C All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or rations building Occupant use equipment or dcvims which If a roof is installed without first obtaining an inspection,I agree to remove
h.mrdoa atr conmminan dc11 d by the Bay Area Air Quality Management all new materials for inspection.
7mquiremen
ic0
E3 Yes
Nn
I have mad the hazardous materials.quiremcnu under Chapter G95of the Califor.
eal"Safety Codc,students 25505,25533 and 25534.1 unaround Nal if the building
not cu tly haw a venal.that h is my responsibility w notify Ne OccuPmt of the
w ' muu 'or iaatweafaccruaca fee . Signature of Applicant Date /
own raamadye gent w All roof coverings to be Class"B"or better v