02110031 CITY OF CUPER'11NO D' • ' sash v :�,ay,�x ;�, ,:
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BUILDING DfvfsloN PERMIT eCONTRACT-ORR INFORMATION. '
BulHrGIf7g4REs8COFIELD DR WM H FRY CONSTRUCTION ACOM INO2110031
WRlAgltP CHAMRAJ 10351 SAN FERNANDO AVE APPLICAT17S}^@7 /2002
BONE: 4 0 8 99-6-8173 SANITARY NO./ CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
pP00 LICENSED CONTRACTOR
underSDEsmewof ION
tZr I herehy afErm that I am licensed antler provisions of Cha ter Y(commencingp SC n
wdhsccron]a1eBect. innanrNenerinesaanarrnrcadnnecn�e.anamynee�wREVISION- -IN S � ONLY
goy in tall force and effect. REMODEL, NO NEW PERMIT ISSUED
DMq? License class Lid.« #02100014
rn Dam Contractor ORIG.
MARCIIFFECPS DECLARATION
I understand my plans shall be used as public records �\
apaV
into
Licensed Professional
OWNER BUILDexempt
ER DECLARATION
Conyr ON O
t�<i 1 hereby reaso .(Seta that 1 1. exempt from the Cssions Co License: nyLaw for the \V S
apo which ingreseta(Section]11]15,Business and improve,
Code:Any can or county C` A
K$ which requires a permit m construct,alma improve,h Permth, fi a a.01 ed statement �GJ
pdor.mhs isscivance.ddpassnnt to the do,viions(ifGm suchpermiuo01co Law(Chapter
ntalheimer,with
pursuant Neprnvivinnn3 oft¢unusines'x License LawlCiole) v Sq.FL Floor Area $306'fiYOation
N�$ (cat he
xempthsecttnn](MdB nl Dosis nJo(thc Business andim.An vi Cnde)of
—
that be is exempt therefrom end the barn for the alleged exemption.Any violation of
Section]031.5 by any applicant for a permit subjects she applicant m a civil penalty of J b Alkf4 t4gNbeVOOccupancy Type
not more than five hundred dollars(9500). P Y YP
0 1,u owner of the propcny,or my employees with wages as Nei,sole mmpenalion,
will do the work,and the swmum is not intended or offered for ale(Sec.704/Business
and Professions Code:The Communis s License Law does WI apply m an owner of 102 - PIERS equtred Inspections
propeny who builds or improves thereon,and who does such work himmlf or through his
own employees,provided that such improvements are not intended or offered for ale.If, 103 — UFER
however.the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving Nal he did not build or improve for purpose of
sale.). 105 - ANCHOR BOLTS
0 I,a owner of the property,ar emlinowly entered,with licensed consacmrs m 106 - SEWER & WATER
construct the project(Sec.7041 Business and professions Code:)The Convector's Li-
eeaeLaw does no,applym.now.,nfpropeny who Wilds weimproves thereon,and. 202 - UNDERFLOOR PLUMBING
whence Law.ace for such projprojectswiNac^mracmr(s7licensed pursuam to the Contruwis
License L 203 - UNDERFLOOR MECHANICAL
D l am exempt under See. .B&P C for this reason 204 - UNDERFLOOR FRAME
caner Dat 205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION 301 - ROUGH PLUMBING
I herebyaffirm under penalty of perjury one crime following deelarmions: 302 — TUB & OR SHOWER
sa I have end will for by
Sector.
37410 of Comm Code.
fart 6rt Worker's Comf the
satinn,a Provided for by Section J]Ikl of de Tabor Code,for the performance of the 303 - ROUGH MECHANICAL
work for which thin pcmait is issued. 304 - ROUGH ELECTRICAL
0 1 have ad will maintain Workcrs Compensation Insurance,as required by Section 3 OS - FRAME
11110n1'Ne Labor Code,for he performance at Ne work(a,which this Permit is issued. 3O6 — HOLDOWNS
My Worker's Compensation Insurance carrier and Policy number are:
Carver: Policy buy: 307 - INSULATION
CERTIFICATE OIo EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 308 - SHEETROCK
rnessection nemnm lecomplcled ifthe pormitisforme handreddollan(5IM) 309 - EXTERIOR LATH
,it lees.) 310 - INTERIOR LATH
I cenify that in the performance of the work for which Nis Pcrmil is issued,I Nall not 311 - SCRATCH COAT
employ any Mann in any manner m as to become subject to Workcrs'Compensation
Laws of California.Dam 313 - ROOF NAIL
Applicant
NOTICE TO APPLICANT.11.after making this Cenificalc of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
Racoma subject a the Worker'a Compensation Provisions of Ne labor Code.you must 502 - FINAL PLUMBING ENERGY
OO BathwiIt comply with such provisions or this permit shallbe deemed revoked.
z 503 - FINAL MECHANICAL ENERGY
CONSTRUCTION LENDING AGENCY
n I hereby WErm that there is a construction lending agency for the Performance of 504 - FINAL BUILDING ENERGY
ai >
'he work lfor which this Purnoisissued Sm.3W7.Civ.C.) 505 - FINAL ELECTRICAL
W Q Larder's Name
]Z 1<ndm Address 506 - GAS TEST
U O 1 cenify that 1 have read this application and stare that the above information is 507 — FINAL PLUMBING
W F' comet.l agree to comply with all city and county ordinances and state laws relatingm
Wilding Construction,and hereny.nmotiza rcpmanmtivea nrwscity u,enter apnn tbe 5 - FINAL MECHANICAL
above mentioned property for inspection purposes.
> w� 509 - FIN GRADE
(We)agree In save.indemnify and keep harmless the City n(CuPeninn against
��. In Iiahilitics,judgments,costs and expenses which may in any way accmc against said City 5 NT G / J
in
his Peorm.
U APPLICANT UNDERSTANDSof by, raden,of IAND WILL COMPLY WITH ALL NON-POINT Issued by51 WORK`S Date
SOURCE REGULATIONS.
Re-roofs
HAZARDO
Signature of APplicaHAZARDO Dam
US MATERIALS Oslum or handl Type of Roof
Will dineapplicant or Tums building occupantentreor handleNmaterial
a defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
^ode,Secthmn zss3z(a)p All roofs shall be inspected prior to an roofing material being Installed.
❑Yea El No P P Y g g
Will the applicant nr future huilding occupant a.equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
immi hazardous air contaminants as delood by the Bay Arca Air Quality Mawgcmcm all new materials for inspection.
Diaricl'1
Dyes 0 N
I have mad the hazardous materials requirements under Chapter 6 Y5 of the Califor.
nia Iicalth X Safety Chadd.Scctioa 25505,255]]and 25534.1 undcmmnd Nm if the Wilding
does not currently hale a tenant,that it is my responsibility to notify the occupant of the
requirements which mum be met prior to issuance of a CeruOcate of Occupancy. Signature Of Applicant Date
Owncrnramhnrizcdagent Date All roof coverings to be Class "B" or better