03070082 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CON,TRACTH ORAM MATION
BUILDING ADDRESS: DIAS JEFFREY AND JEANNE W PERMIT NO.03070082
`q99 R12Ar-TBTE) DR
�hfAME7 PERMIT LSUE DATE
PHONE: SANITARY 90. ONTROL NO.
ARCHITECDENGINEER: BUILDING PERMR INFO
SLOG ELECT PLUMB MECH
0 0 0 0
loo LICENSED CONTRACTOR'S DECLARATION
m 1 hereby effort that 1 am licensed under provisions of Chapter 9(commencing Job Description
fa� with Section 7010l Division Sof NC Busiresand Profession Cudc.and my license is
=qFp full ad CfICC
t.
i'= ADD 1231 SQ. FT. /REMODELDccae Class Lac.x
na Cunrcmr - FINALE[
p
E`
l
'- 'J` ARCHITECTS DECLARATION
I understand my plans shall W used as public records
AN {{,�(1{�
C u.E.U Licensed Professional1UUU
g OWNER-BUILDER DECLARATION
<S I hereby affirm Nat 1 am exempt from Me Contractor's License Law for the
00 following mason(Section 7031.5,Business and Professions Code:Any city or county
`<m 8�. which myWms a permit to construct,alter,minnow.demolish,or repair any structure no Rog gll
prior or its issuance,also requires the applicant for such permit to rile a signed statement
"crop that he is licensed Pursuant to the provisions of the Contractors License Law(Chapter 9 Sq. Ft. Floor Area a0lotd
3t- (commencing with Section 7")of Division 3 of the Business and Professions Code)or
-�cic)nc?nnr nn
that he is exempt therefrom and the basis for the allege-0 exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number
not mom than five hundred dollars(ssoB). -- - - -- Occupancy Type.
❑I.as owner of Be property,or my employees with wages a their sole compensation.
will do the wart.and thcxrucwm is not intended or offered fonale(Sex.7044.Bu;"e,• 101 - FOUNDAIgG4lAbd Inspections
and Professore Code:The Co...,',License Law dors oat apply he an owner of
property who builds or Minorities themon,and who doensuch work himselfor through his 102 - PIERS
Own employees,provided that such improvements are not intended oroRered forsale.If, lO3 - UFER
however,me building or Improvement is sold within one year of completion.the owner 103
will have the burden of proving that be dm not Wild or improve for purpose of 104 - REBAR
sale.).
❑ 1.as owner of the propcny,am exclusively contracting with licensed contractors to 105 - ANCHOR BOLTS
construct the pmject(sec.7W4,Bwioess and Professions Code:)'Ihe Contractor's Li 106 — SEWER & WATER
cease Law does not apply to an owner of property who W;Ids or improves thereon.and
who contracts(at such projects with a eonsacarts)licensed pursuant m the Contractor's' 202 — UNDERFLOOR PLUMBING
InIanamense 203 UNDERFLOOR MECHANICAL
.s lam exem(�p/tr7/underS w ,B&PC(or f-r' n 204 - UNDERFLOOR FRAME
I WORKERS COMPENSATION DE 'ATION� 205 - UNDERFLOOR INSULATION
. ' I hereby affirm under penalty of perjury one of the fo0owing declarations: 3 01 — ROUGH PLUMBING
❑ I haw and will maintain a Certificate of Consent to self-insum for Worker'sComren- 302 — TUB & OR SHOWER
Much,as provided far by Section 3780 of the Tabor Code,for the performance of the 3 0 3 - ROUGH MECHANICAL
work for which this pe.it is issued.
❑1 haw and will maintain Workers Compensation Iruurwcc,as an rind by Section 3 04 - ROUGH ELECTRICAL
3708 of the labor Code.for dm pttroomusce of the work for whim this permit is issued. 305 — FRAME
My Workers Compcnvtion lnsunnce carrier and Policy number are: 305 — FRAME N9
HOLDO
Carrier: PolicyNo.:
307 - INSULATION
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 308 - SHEETROCK
or less.)
section need not W completed if prom,is for one hundred unit=($100) 309 - EXTERIOR LATH
1 mrtBy Nat in the pert anec of the wort ter which this Norot n bsued,1 shag nal 3 10 — INTERIOR LATH
employ anyprow aacr to esu cttosW Worken'Com nation
lawsar Car( - - __ -:g N 311 - SCRATCH COAT
Ap 313 - ROOF NAIL
NOtT��E TO APP NT:r(afer making this Cesificatr of Exemption,you should
WteMb subjat to the Worker's Compcwtion previsions or me labor Ced,you must 501 - FINAL ELECTRICAL ENERGY
)� romwithComply waM1mmPrnv;smnsorthis P midananWdremedmvam°. 502 - FINAL PLUMBING ENERGY
z CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
1 hereby Mrm that there is a construction lending agency lot Be Performance of
Y > the work for whim this permit is tamed(Ses,3097,Civ.C.) 504 - FINAL BUILDING ENERGY
13. fender's Address Leaders Nam` 505 - FINAL ELECTRICAL
ZZ 506 - GAS TEST
;J Q 1 Certify that 1 haw read this application and sale mat on aW w information is
.L F correct,l agree to comply with all city and county oNmances and sore laws relating m 507 - FINAL PLUMBING
Z) V building convection.and hereby autharim repreaenWves of this City to enter upon the FIN MECI CAL
ahovomcntiuned property for inspection purposes.
L LL (We)agree to ssrc,indemnify and keep M1arerim the City of Cupertino against O(.� F I
to liubiliticajudgmens.costs and uPenses which may in any way acme against said City 5 NG 'I\
JZ in consequence of the granting of this armil. L/
WC
SOURCE RAPPLICAE UNDTROST NDS AND WILL COMPLY WITH ALL NON-POINT Issued by:5 Dale
0' l&_
Reroofsngnaturc pl'c HpACZoARD0U5 MATERIALS DISCLOSURE More Date
Type of Roof
Will the applicant lir forum building uccupanutom err handle haraodous material
as defined by the Culsenmo Municipal Code,Chapter 9.13,and the Health and Safety
Section 35533(a)?
C]yes goNo All roofs shall be inspected prior to any roofing material being installed.
Wili the applicant If a roof is installed without first obtaininginspection,I agree to applicantoe future ducupant tax cyuipmcm or devices which an remove
mit hatr dous air co m ormars as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes �No
1 have mad the havaNdms materials mqu;mmeres under Chapter 695 of the Califor-
niaHcalthXsafcdyCodC,Scctiurs 35505.35513 am12553C.I undcrsland thv ifmc Wilding
does not currently haat a renand,that it u my reaponibilily 0 notify the aeuPwt of the
MIN,hrcnts whichU Wmet Apto ssuance of a Ceraficae ofenpancy. Signature of Applicant Date
Z44�_ 00
r or author dagent Dade All roof coverings to be Class "B"or better