02120046 CITY OF CUPEWI'INO
BUILDING DIVISION PERMIT GONTRAC-TOR INFORMATION:
BUILDING ADDRESS: TERRY BROWN PERMrr NO.
10230 SCENIC BLVD 02120046
OWNER'S NAME: APPLICATION SUB DATE
TERRY BROWN 12/11/2002
IONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 t�
wo, LICENSED CONTRACT'OR'S DECLARATION
P 1 bereby alltrm that I am licensed under pmvi.sions of Chapter 9(commencing Job Description
with Section 701X1)of Division 3 of the Business and Profassions Cole.and my license is
in full once and effect. ELECT UPGRADE TO 200AMP /� e
ozg License Class Connemr FINALED
MMARCHITE-CTS DECLARATION
I understand my plans shall he uaod as public records
t:t1 L hicensd Prn essinna
APR 2 9 2003
C v.G Oat I am BUILDER DECLARA'T'ION
fri OO I hereby reaso .(fete that 11. exempt from me Contrastars :License law for the WILDING—p0 followwhichinguircaa Permit
]03LS.Busaor,Trp win der ileCode:Any city r county
modow. WILDING
Z� which requites a permit re requires
alter.improv,n Permit
it m repair any etrwwre
poor m int issuance,also rcquiree she applicant for such permit m lilt a signed statement
tF=Fs�s< that
mecing licensed with
pursuant to the of Division
of the Contractor's Li2nselsw(Chxp)it Sq. Ft. Floor Area $1g�rll3hOn
NF$ that he
(commencingion rom ad nl Ideas for
oft he Business and
on.Ayvi Cote)it
rt3� That he is exempt therefrom and the hazis far me alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty,of Occupancy Type
nor more then Eve hundred dollars($5110).
❑ I,as owner of the property,or my employees with wages az their sole compensation,
will do the work.and the structure is not infrared or offered for sale(Sec. Business ±63 UPER ,g��1{ �p Sp��(
and Professions Cole:The Contractors License Law does not apply m an owner of 304 - ROUGH IST.rLl. VTatIDns
properly who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If. SOS — FINAL ELECTRICAL
however,the building or improvement is sold within one year of completion,the owner,
builder will have the burden of proving that he did nor Wild or improve for purpose of
sale.).
❑1,es owner of he property,am exclusively contracting with licensed contractors m
construct the project(Sec.7(X4,Business and Professions Code)The Contractor's Li-
cense law does not apply to an owner of property who builds or improves Ihemon,and.
who ntracts for such projects with a contracmr(s)licensed pursuant to the Contractors
'e Law.
/xc gw"rr Sec. B @ P C for this reaz n
E �//�a � 2
O. 74 Date IOL
WORKS S MPENSATIONDECLARATION
1 hereby allirm under penalty of perjury one of she following declarations:
I have and will maintain a CcniBcate of Consent to sclGinsum for Worker's Compur
sation.ex provided for by Section 3700 of the Later Gude,for me performance of the
work for which this permit is issued.
F,1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of Ne Labor Code,for Ne performance of the work for which this Pumif is issued.
My Worker's Cnmpensarinn Insurance Darier and Policy number arc:
Carrier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be cnmplemd if the permit is foronc hundred dollars(Slap
or lem.)
1 certify that in rhe performance o,the work far which this permit is issued,I.¢hall not
employ any Perste in any in sit as It)bemmc 1z to 11 Workers'Compensation
Laws of California.Dooms,
�L
Applicant
NOTIC APP. :IL a ter making Nis Ctniticac of Exemption,you should
becnm s jca m the Worker's Compensation provisions of the Labra Code,you must
O O bvthwi comply with such provisions ser This permit shall be JeemeJ rcvnkeJ,
z CONSTRUCTION LENDING AGI7NCY
[—s N I hereby affirm that there is a construction lending agency for the performance of
f1i 7 the work for which this Pum it is issued(Sec.YN7.Civ.C.)
0., `� Under's Name
4Z Lender's Address
U 0 1 cenify that I have read this application and stem that the above information is �l(/
� ,P coned.l agree to comply with all city and county Ordinances and state laws reining to / )
�U building coaxwetinn,and hereby noun re represemarives of on,city to eine,upon the v
W aMwc(We)agree
toes save,
for emnif an keep of
1
(We)agree to cove,indemnify and keep harmless the City of Cupertino against
against
V) in
equnce of ts,the costs and expenseswhichit. may in my way ascmc against gold City v V
U z A APPLICANT
of UNDERSTANDS
of this permit.
�+ APPLICANT UNDERSTANDS AN WILL COMPLY WITH ALL NO -POINT Issued by: Date
SOUR IONS. i
1&e-roots
Signamrc of Appl mVCmnh.clm de
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupanutore ser handle formed...material
efined by rhe Cupcnino Municipal Crate,Chapter 9.13,and she Hcalfh and Safety
101,c.Sc Y a 255321¢)? All roofs shall be inspected prior to an roofing material beim installed.
❑Tea Nn P P Y g g
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emir hrtallous air contaminants u defined by me Bay Area Air Quality Management all new materials for inspection.
D slrlel? 91
❑yes
I have mad me hamodnus materials requirements under Chapter h 95 rf the Cali for-
fin Heaph&Salcey Code,Swoons 255115,25533 and 25514.1 undersmnU mall thc mining
does nor cu rcmly haw a bound.that It only responsibility m notify fore Otto fQnlot me
requirementsw ' stbeme no issuance Of.CenifcalrofQ�lpe�y.�/O Signature of Applicant Date
Ow aumnn/Cd agent /7/bare All roof coverings to be Class"B" or better