02090056 CITY OF CUPERrINO
EOn.nINC ntVISION PERMIT CONTRACTOR IN,F�,ORMATIQNt,,:�
BDI'1!9WIYiN79 STEVENS CRK BLV PINN BROTHERS CONSTRUCTIO gRMIFN02090056
9-sldI3fE:BROS . CONST. 1475 SARATOGA AVE nPPLICAT9r YU)9)12002
PHONE' (408) 252-9131 SANITARY NO. CONTROL NO,
ARCIII'IPCTA NGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECll
0 0 0 0
w00 LICENSED CONTRACTOR'S DECLARATION
m w P I hereby affirm Ibar 1 am licensed under prnvixions of Chapter 9lrarmmeaning
G« with Section7000)nfDivisionla(theBusinessandProfessionsCalc,andmylicense is '� iT —DEFERRE� SF ''E1�IR�i'AL
t_om in full force and effect. (#01050180 FOUNDATION PERMIT,
nZ laceClava Lie.at
0ZFWrum Dale tm
Conctm ORIGINAL #01070014)
ARCHITI'CPS DECLARATION
< I understand my plans shall be used as Public rccnNsar
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LL"I vItV
3Oa LiccnvcJ PnJcssinnul _p
OWNERexemptfi DECLARATION v
ax I hereby affirm that 1 am exempt from the Contractors License Law(or the
E se
00 following reason.(Section 71131.5.Business and Professions Code:Any city nr llmnly
n't,$ which m9vires a permit m construct,alter,improve,demolish,or repair any structure
're—'^ prior In its reaconce,also requires the applicant tor suchlerm it In file a signed statement
that he is licensed pursuant it)the provisions of the Contrwitir's License Law(&IFIcr 9 Sq. Ft. Floor Area $851M&i10n
z0 (commencing with Scction 70()(1)of Division Iof the Business and Professions Code)or
y;$ Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 703 L5 by any applicant for a permit subjects the applicant n a civil penalty of IkFt
not more man Bre hundred dollars(s50). Occupancy Type
01,as owner of the property,or my employees with wages as Meir wle compensation,
will do the work,and the structure is not intended or offered for sale(Sec 7(W4,Business Iela
and Professions Code:The Contractor's License Law Jens not apply w an owner of 102 - PIERS egwred Inspections
property who builds on improves thereon,and who does such work himself or through his
nWwemployees.provided that such improvements ase not intended or offered for to If. 103 — UFER
ever,the building or improvement is sold within one year of completion,the owner. 104 — REBAR
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.), 105 — ANCHOR BOLTS
❑1,as owner of the pragvt am exclusively aonvacting with licensed convenors no 10 6 — SEWER & WATER
construct the project(Sec.70.14,Business and Professions Code:)The Contractor's Li-
cc rise Law does not apply to an owner of property whit Wilds or improves thensan.and 202 - UNDERFLOOR PLUMBING
who consumer for such projecer with a contrachous)licensed pursuant to the Contractor'a 203 — UNDERFLOOR MECHANICAL
License Law.
I am exempt under Sec. .B to P C for this reason 204 — UNDERFLOOR FRAME
mer Date 205 — UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION 301 - ROUGH PLUMBING
I hereby affirm under Penalty(if Nqury one Of following declarations: 302 - TUB & OR SHOWER
❑ l have and will maintain a Cetifcam of Consent to self-imaro for Worker's Compeer- 3O3 — ROUGH MECHANICAL
sating as pnsvidcd for by Section 37(X1 ab
of the 1-mor Code,fur Or performance Of the
work for which thispfmirsissued. 304 — ROUGH ELECTRICAL
❑1 have and will maintain Worker's Compensation Insurance.as equired by Semon 3 05 — FRAME
3700 of be V ben Code.for the performance of the work for which this permit is ix uc 1.
My Worker's Compensation Insurance corricr and Policy number am: 306 — HOLDOWNS
Carrier: Policy No.: 307 — INSULATION
CERTIFICATE OF EXEMPTION FROM WORK GBS'
COMPENSATION INSURANCE 308 — SHEETROCK
(This remota need not W e eldcledif the permit is for one hundred dollars(3100) 309 — EXTERIOR LATH
nrless.l 310 — INTERIOR LATH
I rectify that in the performunce of the work lou which this permit is issued,I shall not 3 11 — SCRATCH COAT
employ any pmmn in any manncr.so as to become subjectm the Workers'Compcnsalion
Laws or Cabmmm Dae 313 — ROOF NAIL
Apirmant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should 501 - FINAL ELECTRICAL ENERGY
become subject an the Worker's Compcnsxtion pnwWonsnl the Labor Code,you muse 502 - FINAL PLUMBING ENERGY
ZZ formwith comply with such provisions or this Permit shanhedeemedeacted. 503 - FINAL MECHANICAL ENERGY
CONSTRUCTION LENDING AGENCY
'rte. 14 1 hereby affirm Oat thin,is a constriction lending agency for the performance of 504 - FINAL BUILDING ENERGY
C' > the work Iorwhich this permit isheard(See.31F)7,Cos.C.) 505 - FINAL ELECTRICAL
w o Lem"I*sNamc 506 — GAS TEST
z _cmhr's Address
U O 1 citify mat I have mad this application and stem that the move information is 507 — FINAL PLUMBING
correct.Iaree to comply with all cit and enure ordinances and state laws relatin to
0 building«oswnion,ndh,eby autnnrim representatives of Ibis city m enter uper the 5 FINAL MECHANICAL
N w OW,c-menronedpropenyfor inepectionpamoses. 09 FIN GRADE
j- M (We)agree b save,indemnify and keep harmless the City of Cupertino against
_, t I liabilities,judgments,costs and expenses which may in any way same against said City 5 N N G
V z APPLICANTeUNDERSTANDSthis
AND WILT.COMPLY WITH ALL NON-POINT Issued by51 WORKS Date
SOURCE REGULATIONS.
Re-roofs 603 - OF BATTENS
Signature of ApplicamsContractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of M014 — ROOF IN—PROGRESS
Will the applicant or future building ucupanl store ser handle harardous material
ift by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
We,Scclinn 255321.1% All roofs shall be inspected prior to any roofing material being installed.
❑Yes 0 N
Will thea applicant of future building occupant useequipment or devices which if a roof is installed without first obtaining an inspection,I agree to remove
Pp d by theit
emitict? us air conlaminaneravJClincJM1ytheflayArea AirQua]ityMawgcm,N all new materials for inspection.
Ui.Nrin%
[D Yrs 0 N
I have read the bvardous materials requirements under Chapter 6.95 of Or Califno-
nia I lalm A Sufcty C(Ac,Soctiom 2551)5,25539 ad 25534,I undersmnd thin if the building
does not currently have a tenant,One it is my resonan bililY Or madly the Occupant of the
requirements which nmetbe fill pnor toOrt,a,enfaccnircaleofOccupancy. Signature of Applicant Date
Owrwrofaumoriedagem Date All roof coverings to be Class "B" or better