02110152 CITY OF CUPERTINO
BUILDING DIVISION PERMITCONTIt`ACTURINF( RMA'�'TpN
w qv, p _ P. sem`. Lam. aff.y.,satlbn.,
BUILDPERMIT�(J ING ADDRESS: PERMIT NO02110152
UOE2 110 1 5 2
rc;r, RANDY IN
°R'S NAME: 'A5/2003
�M & NOELLE MATHEWS
ONE: SANITARY NO. CONTROL NO.
ARCHITECTENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
1 homby aMrm that I am licensed under provisions of Chapter 9(commencing
Job Description
with Such..700p)of Divishm 3 of due Business and Prufctshms Code,and my licana is
�D. in full to eandeffat 360 SQ. FT. LIVING SPACE ADDITION FINAL
Ice
j z Liamc Clues Lm.g
Dam Contractor 400 SQ. FT. GARAGE ADDITION
3p�p ARCHITECTS DECLARATION
ti's I understand my plans&hall he used a public records APR 29- 2004
72!U
3Q� Licensed Prafeammil
OWNER-BUILDER DECLARATION
ii 1 hereby affirm that 1 am exempt from the Contractars License Law for the BUILDING
yn0 following lesson.(section 703 1.5.Business and Professions Cale:Any city or county ,Y
K a Ix which requires a Permit to construct alter,topmost,demolish.or repair any structure
prior to its iavance.alamquires thcappliemt fluxion permit to filc.mirmdsmmmem
<
that on,islicensed purauamtotheprovisionsofthe Contractor's UK nacLaw Chapter 9 Sq.Ft.Floor Area Valuation
as 1- (commencing with Section 7")of Division 3 of the Business and Professions Cede)or
mal he It exempt thuefmm and the bass fru the alleged exemption.My violation of $150000
Send..Tml.5by,rtyappli«m(a,apermit subjects the applicant m,avd pc rally of APN Number Occupancy Type
net mom than Bw hundred dollars({500).
01,u awau of the Property.or my employees wird tete u their sole compensation, 31602067 . 00
willdodmwark.andmutructure isnot intended or oRemd for We(San.7014,Business RRce(�i d Ins ections
and Profeuom Code:The Convectors License taw dean al apply to an owner of 101 - FOUNDAT'rU P
progeny who bullds orimprows thereon.and who doessuch wo lthimself or through hi,
own employs,provided met such improvements are not intended oroRered for sale.If. 102 - PIERS
however,the building or improvement is sold within arts year of completion,me owner.
builder will new the burden of proving mal he did not Wild or improve for Indio¢of 103 - UFER
sate,) 104 - REBAR
1,a owner of the propeny,am exclusively contracting with licensed cenmetm&to 10 5 - ANCHOR BOLTS
construct me project(Sec.2044,Business and Professions Cade:)The Contractor's Li.
came law does not pply to an owner oFropeny who Wild,or improve themon,and, 106 - SEWER & WATER
who contracts for such projects with a contractor(,)licensed pursuant m the Contractors
License Law. 202 - UNDERFLOOR PLUMBING
❑I,m exempt under Sec. .B A,P C far the moon 203 - UNDERFLOOR MECHANICAL
mm
S-15-03 204 - UNDERFLOOR FRAME
WORKER'S COMPENSATION DECLARAN
I hereby alRrm ander pewty of perjury ane of the hallowing decl,ratiom: 205 - UNDERFLOOR INSULATION
❑inns end win mainuina CutiBwte a(Consemtouu-insure(orworket,compem 301 - ROUGH PLUMBING
orlon,a provided for by Sation 37M of We Labor Code,far me Performance of me 302 - TUB & OR SHOWER
work farwmehthisPermitisiatuea 303 - ROUGH MECHANICAL
I hew and will mainuin Worker's Compensation Issuance,a required by Section 3 04 - ROUGH ELECTRICAL
J?00 of the labor Code,for the peRormantt of me war
for which this permit is ivied.
My Workers Compemauon Insurance tinier and Polity number art: 305 - FRAME
Came,: Policy Ne.: 306 - HOLDOWNS
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 307 - INSULATION
(Dissection need not hecomplelad lithe Permit is foram hundamdallas(SIM) 308 - SHEETROCK
&rte"') 309 - EXTERIOR LATH
I comfy that In me performance of the work for which this permit is issued.I shell nm 310 - INTERIOR LATH
employ any person in yme nets set come subject to the Workeri Corepemation
Lawserc6�Rraa�y� c -f�-� 311 - SCRATCH COAT
NOTIC5$0'APPLICANr:If,after making this Certificate of Exemption,you should 313 - ROOF NAIL
become ubjmt in me Worker's Compensation provisions of me Uttar Carlo,you must
.JO foMwith Comply With such pmvisiomorthis Permit shanthe deemed mmked. 501 - FINAL ELECTRICAL ENERGY
Z `- CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
(:. .N., Ihereby IMM that them s,construction lending agency for dmperformanaof 503 - FINAL MECHANICAL ENERGY
C'> me icwhich Nspermit sissoed(Sa.]l19?,Civ.C.)
Qtandc504 - FINAL BUILDING ENERGY
Nam _ /I
Z d r,Adn .. 505 - FINAL ELECTRICAL
U O 1 certify that 1 nave ad this application sold Auten
te mve e show in(omI W on is 506 - GAS TEST
U.
correct.t.es t. e I qua to comply with all city and county ordin,nas end sate laws relating to
C) building construction.and hereby authodarepreanuthasofthis city menterupondm PLUMBI G
` W above-mentioned pmpcny for inspection purposes %FINAL
FIN L
(We)agree m save,indemnify and keep t a eless the City of Copenina,gaiwliabilities,judgments.coxa and expenses which may in any way accmc against aid CityUZ in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: NG Date
;SoU EGULATION
5 IS_p Re-roofs
ewrt ofApplicaHAZAmRDOUS MATERIALS DISCLOSURE DamType of Roof
Will me applicant ser future building mnurpantsmre or handle hazardous malarial
efined by the Cupertino Municipal Cod,Chapter 9.12,and the Health and Safety
$mile.25532(.)? � All roofs shall be inspected prior to any roofing material being installed.
Oyu [p Ne
Will the applicant or future building occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
hrardom air comaminana ss donned by than Bay Ara Air Quality Management all new materials for inspection.
ict?
❑Yes r3No
1have hand the ha ndahs materials requirements under Chamer695ofthe Califon
niaHalmh Safety Cok,sfim 25]03,25573xnd255la.1unMrmmuftheifthe Wilding
docs not nodded,have a meant Was it s my responamility In truly the eceupant of the
requirements which mut t arm sans enc -lines,or Occupancy. Signature of Applicant Date
A�iGws. S Irl a�
O cr onumarized agent ,s, All roof coverings to be Class"B"or better