03030132 CITY OF CUPERTINO
BUill DIVISION PERMIT 'XONT"C,TQWIN�q ATT!
BUILDING ADDRESS: S A DAVIS & ASSOCIATES """03030132
r;r)g RAMPART All
still NAME: 4856 EL CAMINO REAL 719�"57/2003
AN MELLO _ A,
(650) 567-9001 sANTIARY NO. CONTROL NO.
ARCHTTECTIENGINEER: BUILDING PERMIT INFO
BLDGE9 MECH
PLUMB
0 LICENSED CONTRACTORS DECLARATION Job Description
�w I whaby affirm that 1 licensed seat provisions of Chapter 9(Commencing
Z with i. �gi .7q of Of I fi.MM E..siX And IMICOssirom,Cole,And my license I.
cosia asci
90 ADD 695 SQ. FT. /REMODE FINALE0
fit
t,g se gual L
Lmen —
M 4 DAM lmlgr7
val- ARCH t4ATION
I tmd�3Iml libe 18B17 ru NOV 0 5 2003
3w� Licensed Proficsintoffall
OWNER-BUILDER DECLARATION
�g2 g I thereby affirm that 11. exempt from one Contractur's License Law for the BUILDING
a following Mason.(Section 7031.5,Business and Proffessions;Code::Anse
or county
�1er which requires a Permit to InnstrOct.alter,improve,demolish,or repair any structure
,_�er poor U)its issuance,also requires the applicant forsuch permit to file a signed statcomm
1H that he is licensed pursuant to the prevision of the Contriscor's License Law(Chapter 9 Sq. Ft. Floor Area $3 0 0)l
(commencing with Section 7000)of Division 3 of the Business and Proessims,Coam)or
that he is exempt flocatfroser,and ft basis for this alleged exemption,Any violation of
Section 7031.5 by toy Applicant for a Permit 911buCts be AppliCAN III a Civil family Of 3 @&Net"erO 0 Occupancy Type
Out anow don,five hundred dollars($500).
0 1,As Owner of He property,a my canployces with wages,As their sole Compensation,
will do the work.And Meanet..isnot intended or offered f...1.(Sec.7044.B.Ciricat iui - YUUN"Al
And Priffewhom Coxic:The Comosclon's Licause,Law dwai And apply in an ourser of Te
ppropertyproperty who builds orimproves thencon.and who does such work hicirstafforthincouth his 102 - PIERS �Igd Inspections
orwricesployces,provided IIAL such improvements AM not museduil corroffered(week,If. 103 - UFER
however.the Wilding or improvement Is mid within am year ofecomplation.the overer
buildice,will have mic burden of proving chat At did am Wild a improve for purposse,of 104 - REBAR
"]a.). 105 - ANCHOR BOLTS
0 1.As oweer of the pmperry.am exclusively contracting with licensed constranciums an
...=I the project sce.7044,Business sad Penfundmis Coat The Combrowtor.U. 106 - SEWER & WATER
wouse Law dome not.pply in an Owner ofinroperty who Wild,or improves thereon.tied
.he countract,to,swin projects whilb A ccourecur(s)licensed pursuant tithe Gartmemuse. 202 - UNDERFLOOR PLUMBING
License 203 - UNDERFLOOR MECHANICAL
0 larronexcurplundersem. .B&PCfcAimsMxwm 204 - UNDERFLOOR FRAME
at 205
—DAM— - UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION
1 hereby effinnn under penalty of perjury am of the following c1cclarraflons, 3 01 - ROUGH PLUMBING
I haw and will maintain A cinnonexte urcmacia mulf-imore far Workers Compen. 302 - TUB & OR SHOWER
sation,As proAdcd for by Section 3700 of the Labor Cade,for live performance of thic 303 - ROUGH MECHANICAL
work for which this permit is issued. 304 - ROUGH ELECTRICAL
a
rl I haw and will maintain Worker's Compensation Insurance.As required by Seddon 1370WC,of the Labor Code.for the performance of me work for which this permit is issued 305 - FRAME
My Works CwI7 Whom mm ruct carrier and Polley num I AM: 306 - HOLDOWNS
ir . Cy No.:
not
`7 N"0'
ATIFICATE OF 4LF�Ro WOI'KmFRS? 307 - INSULATION
COMPENSATIONIN 'CE
NCE 308 - SHEETROCK
as fien wed not Mcomplctcd ifft Permit Is forone hundraddollars($100) 309 - EXTERIOR LATH
or Ica.)
I CCOAfY than.in me performance of Me work for which this permit is Issued,I slash not 310 - INTERIOR LATH
employ any person in Any answer an As W become mbjcci to ft Workars'Comperaillon 311 - SCRATCH COAT
Law OfCAIUwdL DAM 313 - ROOF NAIL
Appl�lxm
NOTICE To APPLICANT:If.after making this Cordlicauc of Exemption.you should 501 - FINAL ELECTRICAL ENERGY
beccom subject in ft Work..a crofactuatum pro,inchns of the Lalwar Code,you cand,
Z forumviO comply with such Provisions or this permit shall Ise dearroul Mimutd. 502 - FINAL PLUMBING ENERGY
zit CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
P:4 1 Variety&Mm that there is A constrourcunn lending agency for eve parponnarso,of 504 - FINAL BUILDING ENERGY
C4„> on,work for which this purnall 1,isload(See.3M7.CN,C.)
W in Laad.e: 505 - FINAL ELECTRICAL
0. 1.4mice Add.
D z 506 - GAS TEST
1 certify chat I have read this application and sum that me above information is 507 - FINAL PLUMBING
Correct.I agree to comply with all city and county remittances and snam haws relating to
0 U building construction,And hereby authories representatives ofthis city to enter Orion the FINA MEC1H1A11LNj CAL
FI
above-mentioned property for Inspection purposes.Ll 09 FIN 0AT"117
(We)agree It un,indemnify tied keep herrintes,the City of Cupertino against
rn Ifittellitica.judgrorms,costs impeparcies which may in any way acccom against mid City S G
U 4 in conzatiocrica of ffic SumAjoiftmonsit.� S
APPLICAN'T UNDERfA7NS AND Wir MPLY WITH ALL NON-POINT Issued by:5% WORKS Date
$OUigttE REGULATI S. __A 1i — —
V _4-97-01 Re-roofs
Signature ofArplicam/conmecior — �Dmsc
HAZARDOUS MATERIALS DISCLOSURE Type ofRoof
Will the.pplicam orfuLum building acupmt emm ar handle hmallous material
as defined by the Cupertino Municipal Code,Chapter 9.12.AM the Health and Safety
SO,fl..255324)? All roofs shall be inspected prior to any roofing material being installed.
0 Yes �N.
Put,
Will the Applicant or future Wilding Occupant tom eqUiplumonft Or&VICCA which
If a roof is installed without first obtaining an inspection,I agree to remove
Into,hazardous air contarromms as Oct by ft Bay AMA Air Quality Management all new materials for inspection.
District?
e101YC3 ICN.
I -
I mad dim ;�-qalod ma
ou &Safety 5. 25534.t 2M==95 I I`Z C wilding
art
does of currently
Is cons
B ice.7lantenan issuarapelloccilifica of'�-"W'y Signature of Applicant Date
lo" V
enclle_ % All roof coverings to be Class"B"or better
wom,or Inumore,.8.
er.re,or Authorized gCOR Dam