03030096 CITY OF CUPERTINOa '�'y�
BUILDING DIVISION PERMIT dCONJrY2a�"QRINFORMATION
BUILDING ADDRESS: PERMIT N0.03060096
OWNER'S NAME: PERMT.. LSS{tapA 22003
` E: SANITARY NO. / 1 CONTROL NO.
ARCHIIECTIENGINEER: BUILDING PERMR INFO
BLDG ELECT PLUMB MOCK
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LIC CONTRACTORS DECLARATION Job Description
¢ e Mmbyt))of Nel1amrft licensed Bu underpmvivassofs hapter code. 9(mit..is P
n< witallfarrn7daffecpivldon3ofdmBual•...aMRo(cviomCode,andmylicemcie pp���� p1 �o
< infvnmroeaaaercec`' BATHRM UPGRADE �''�tlA6G®
5'z License Class Lie.0 _
' Dam ContractorARcHiTECrS DECLARATION p�
I understood my pl ns ilial M used as pue records Nv V('1/
0 3 2003
DU
yc� Licensed Professional
gy OWNER-BUILDER DECLARATION BUILDING 2 e S I hereby affirm that I am exempt from the Conuneur's License Law for the BUILDING
i OO following mason.(Section 703 1.5,Business and Professions Cole:Any city or county
5$ which nails a permit to connect,alms,improve,demolish,or repair any structure
-zY prior to its issuance,also onuiru tiro applicant for such Permit to file a signed summem
< dot W is licensed pursuant to the provisions of Ne Connector'sLiamc Law(Chapter 9 Sq. Ft. Floor Area C8N"4ion
is a (commencing with Section 7003)of Division 3 of the Bosom and Profusions Could)or
tY'
3 Nat W u exempt Nuefmm and Use buLL for the alleged exemption.Any viol Wan of
Section 7031.5 by any application mr a permit subjects Ne applicant to a civil Penalty of 3 M19ftititier 0 0 Occupancy Type
not mom niton five hundred dollus($500). P Y YP
❑I.uowmrofdepmpwy.wmyemplaymwim"guu Ne mkc mnudon,
will do Ne.&.ad NeeWCIYm Ice Mt Intended IXaBCRd far WC(Sec.70M,Buid. iui — dInspections
and Protecting,Code:The Ci nnactoYa I-,Lav,does moa apply m as owner or
property who boom orimprows thereon,and whudoessuchwork himselfw though his 102 — PIERS
own employers,provided Nat such improvements are not intended aroRered for We.U. 103 - UFER
however,Ne building or Improvement LL sold within one year of wmpletion,Ne owner.
builder will thaw Ne burden of proving that W did vast Wild or improve for purpose of 104 — REBAR
"mL 105 — ANCHOR BOLTS
1,as owner of the propcny,am exclusively contracting with licensed anentors to
construct the project(Sec.7014,Business and Profusions Cade:)The Conb wes U. 106 — SEWER & WATER
come law does cat apply to an owner of property who Wilds or improves therean,nd, 202 - UNDERFLOOR PLUMBING
who contrscufor such pmjecu with acontrxetor(s)licensed pursuant m the Comommfa '
License Law. 203 - UNDERFLOOR MECHANICAL
❑lam exempt undo ,B&P C for this mason 204 - UNDERFLOOR FRAME
ow 6 6 205 - UNDERFLOOR INSULATION
ORKER'SC PENSAnONDECLARATI
(hereby afR A maltyofpeduryowaf NefollmingdalarWom: 301 — ROUGH PLUMBING
awandwill ma ui"Accmifinmofco=nitoalhlmumfmwafk scompen- 302 — 'TUB & OR SHOWER
cation,u provided r by Section 3700 of the IaWr Cask.for the performance of the 303 — ROUGH MECHANICAL
work for which this permit s mem)' 304 - ROUGH ELECTRICAL
❑1 haw and will maintain Workers Compensation Imunncc.as required by Section
»maftheLaborCode.fartheperrarmnaofNeworsfarwhichNLLKnollisissned. 305 — FRAME
My Workara Compensation Insurance carticr and Policy number am: 306 - HOLDOWNS
Cartier. PolicyNo.: 307 - INSULATION
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE 308 - SHEETROCK
mussectio reed not he completed if Ne Posmlt is foone hundred dollan(S 100) 309 — EXTERIOR LATH
car Nu.)unify Nat in Nc p mane of circ work for which this penton is issued.l shall nm 310 — INTERIOR LATH
e anynn
employ any person in mymcrnsstobecome nbjectto NC Workcn'Compewoon 311 — SCRATCH COAT
Apps of California. 313 - ROOF NAIL
nt
NOTICE TO APPLICANT:IL aftor making this Ccrtificato of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become subject to the Wateri Compensation provisions of Ne labor Code,you mug
.JZ mrowihComply with such provisions orthis Permit shall beaccrued ruvnked. S02 — FINAL PLUMBING ENERGY
z 503 - FINAL MECHANICAL ENERGY
CONSTRUCTION LENDING AGENCY
pa .. I hereby affirm that Nem iso construction lending agency for the Performance of 504 - FINAL BUILDING ENERGY
Ne work for which did.permit isissued(See 3891,CN.0)
;4 1 Cnder's Name
505 - FINAL ELECTRICAL0. A
Z enaer,Addess 506 - GAS TEST
U O I Certify that 1 have mad this application and state that Nc aWw information is 507 - FINAL PLUMBING
(-' Correct.1 agree to comply with all city cad county ordinances and sum laws relating to
U building construction,and hereby someone repmxenutiwa of this city to enter upon the FIN MECHAN CAL
a above-mentioned property fm impeWon puTona
(We)agree to tow,indemnify and kap harmless the City of Cupertino against 0 9 FI
incometerdgmcnseaosund eapemesmit. may In any wyaecme against mid City NG
J Z in conrsl judgments.
a Nc granting of this Pamir,
APPLICANT UNOE ANOS A�t�'D WILL COMPLY WITH ALL NOWPOINf Issued by:5 C WORKS Date
SOU CE \a AA 1 O
Re-roofs
Ouse fAppli VCa or am
N RD= MATERIALS DISCLOSURE Type Of ROOF
WIIN cntor(Muni Wal Cde,Chapter
uoreoNndkh Health
asm material
u maned b c Cupertino Municipal Code.CMPmr 9.12.and the RUIN cad Safety
Cook,sec 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
E]Y.
No If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
hazardous air contaminants as donned by the Bay Area Air Quality Management all new materials for inspection.
icft
❑Yes �No
I have mad the hwardammaterlals requirements under Ch incrii.95 of oto Califon
nia HeaIN&Safety Codc,Sechom 25505.15533 and 25534,I undcrnand Natif dm Wilding
dues not Currently hum a Omani,Nati s my respomihilit,m roof,the acuPnt of the
mqui c tau met nor nissuamcafaCcrofuamofOccupytc. Signature of Applicant Date
V y°
0 sora ariv a c D to All roof coverings to be Class nB"or better