03050079 CITY OF CUPERTINO s .Tr'k,
BUILDING DIVISION PERMIT 102 TRACOR INFORMA PION ra
BUILDING ADDRESS: PERMIT NO.111l03050079
3050079
OWNERS NAME: - PERMIT LS(J,je/22/2003
R71< PT.UKF.R
g; r SANITARY NO. CONTROL NO.
ARCHITECTIENOINEER: BUILDING PERMIT INFO
BLDG PLUMB MECH
ELECT
t�
300 LICENSED CONTRACTOR'S DECLARATION 7bDescri tion
e V Mosby osby affirm Nu 1 am licensed under proviai"m o
of Chapter 9(Commencing I)
with Section 7001E of Division 3 of the B.M.and Profession Cods.and my]is..ie
in full farce and eHaet.
Lic.mucclass tic.0 REVISION--IN HOUSE USE ONLY
E1 D0 Contractor
r
ARCH Con DECLARATION NO NEW PERMIT ISSUED ORIG. #01040104
1 understand my plan shall W used in public records
Licensed Pndeen...I
.7 Oat I am amps fount
DECLARATION �\
I hereby.(firm Del 1 1. nempm from fl r fessinss Co License law for the
o o following mama.(Section 7181!,Business;and ova,de Professions Code:Any city m county .p
$ which requires•permit re quire be alma improve,demolish.care a sig any statement V
priormsl issuance,atmntto be be applicant for such reach tofilese Law atatemcm
r•mWm< Nelhcialingwitpursuantmeth)orDprovisions vnkm3 MheStai .and roelaw.Chda)9 Sq. Ft. Floor Area Valuation
F� (cat he
ingwithheNro and the
basis for oflWDueineumd Professions Code)or
� that he is uempr therefrom and due base for the alleged uemptln.Any violation.f
Section 7031.5 by airy applicant fen permit subjects the applicant to a civil penally of APN Number Occupancy Type
not mart than five hundred dollars(SSW).
0 1,..vein of the property,or my cmploycn with wagesa,then sole ermpenaadon, 34222077 . 00
willdo the worli Neaucnm Isnotmundedwrirared for We(Sec.IDN,Basinry Rwired Inspections
and Profession Cade:The Contracrurs License law Claes not apply m e an owner of 9 P
property who builds orimpoeves themon,and whodonsuch warkhimulfor through his 101 - FOUNDATION
own employ=,.provided that such Improvements arc not Intended n.ffarcd for ale.If. 102 — PIERS
however.the building or improvement Is mid within one year ofcompledon.the Owner-
WllderwillhavethehuNanofprovingNathedidwtbuildurimprovefnpurposeof 103 — UFER
alai) 104 - REBAR
t�h is owner of the property,am nclssivess m c°nuacung with licensed contractors
m
Convect does Out apply in
Owne of
ty who
vds orOThavetthemor,Li 105 — ANCHOR BOLTS
ccou law don not apply a an owner df property who Wilde or improve Centro,and 10 6 - SEWER & WATER
who contracts for such proJecta with ac.ntrmtoKal licensed pursuant to flme Conuaclar's
Lice"=law' 202 - UNDERFLOOR PLUMBING
❑lam see under gee. .Bh PC fn Nu mason
7ta 203 - UNDERFLOOR MECHANICAL
ow"er Date 204 - UNDERFLOOR FRAME
/ WORKER'S COMPENSATION ECLAR Data
I hereby iffin under penury of perjury am of dte following declensions: 205 — UNDERFLOOR INSULATION
I have and will maintain a Certificate.1
Consent m self-inane for Workers C.mpen- 301 — ROUGH PLUMBING
guide.ss provided for by Section 37M of the labor Code,fn flte perfmmatue rf be 302 - TUB & OR SHOWER
work for which Cis permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,a mquirtd by Section 303 - ROUGH MECHANICAL
3700 ofthe LaWrCode.for the performance of the work far which this permit is issued. 304 — ROUGH ELECTRICAL
My workers Compensation Insurance cerin and Policy number art: 305 — FRAME
Cartier. Policy No.:
CERTIFICATE OF EKEMPION FROM WORKERS' 306 — HOLDOWNS
COMPENSATION INSURANCE 307 - INSULATION
(Ihlasectl.n wed not uncompleted if the permit]a intone hundmddollan(SIM) 308 - SHEETROCK
car Ina)
I aNfy that in the pnf°nnancc of due work for which Cis pconit u issued,l thall not 309 - EXTERIOR LATH
employ any person in any manners in in become subject o the Worken'Competnation 310 — INTERIOR LATH
vpliicoan;alifrmia,Dau 311 - SCRATCH COAT
NOTICE TO APPLICANT:If,after making this Cceificam of Exemption,you should 313 - ROOF NAIL
become subject to be Worker's Compensation provisions.f the labor Code,you must
.,z forthwith comply with such provision or this permit shelf tic decreedmvoked. 501 — FINAL ELECTRICAL ENERGY
?oCONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
(•sem tbotchy affirm that them is,contraction lending agency for the perarmanmof 503 - FINAL MECHANICAL ENERGY
C> du work fur which this permit la issued(Sec.3097.Civ.C.)
Wq Landers Name 504 - FINAL BUILDING ENERGY
a z andereAddrca 505 - FINAL ELECTRICAL
V O 1 certify Nat 1 have read this application emission Cat the above thrown.u 506 — GAS TEST
0 F cornam I agree to comply with all city ad county ordinance and slaw sews reining m
V building convection,and hereby authodae rcpntsentariveS Of Cis city to enter uPnn the — FIN PLUMB G
W echos-mentioned properly for Inspection purposes.
(We)agree m save,indemnify and keep harmless Ce City.f Cupertino againr 0 8 F I AL
y s permit. I
liabilitin,judgmens.costs andexpensos whichmry in any way erne gainer aid City 5
in
of the
V APPLICANTeUNDERSTANDS Aoading of mND WILL COMPLY WITH ALL NON-POINT Issued by: 5 ftWING Date
S
ou Ecuun s PUBLICWORKS
S�i1/e�j Re-roofs
Signature of Applicant/Contractor Date 6 2 OOF PLYWOOD NAIL
HAZARDOUS MATERIALS DISCLOSURE Type of Rod 3 - ROOF BATTENS
Will due applicant or rumrc Wilding.ccupant core or handle hagrdous materiel
as defined by the Cupertino Municipal Code.Chapter 9.17,and the Health and Safety 604 - ROOF IN-PROGRESS
tide.Seed..8532(a)7 All roofs shall be inspected prior to any roofing material being installed.
Oyer 9�d
Will the applicant at future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit haxardom air contaminans,w defined by flue Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes Idtv'o
IhavemCyCadi Soced 25305.25533 and
5534.1 examine d.95 rflhe Wilding / J�
nu Hcolth@rently hams on,shoS0A 25513 wW7553a.1 indcnmdthaccup Wilding /ALJ L/ .
Jan not Currently how a he I Wt It i my responsibility in notify flue Pan of the
mquyoE wm<h in" Ito Me Pan
pawyZ/ Signature of Applicant Date
Owner or author ^� All roof coverings to be Class"B"or better