03010115 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTORANFORMATION �3
But
ADDRESS: PERMfr NO.
19930 STEVENS CREEK BLVD 03010115
NER'S NAME: APPLICATION SUB DATE
RIB CRIB 01/22/2003
PI ZONE: SANITARY NO. CONTROL NO,
ARCHITEC ENGINEFI: BUILDING PERMIT INFO
BLDG ELECT PLUMB SUCH
0 0 0 0
Oita,
LICENSED CONTRACTOR'S DECLARATION Job Description
�U F I hereby affirm that I am licensed under provisions Of Chapter 9(commencing p
�u with Section 7tgMB of Division 3 of Ne Business and Profimcdnns Code,and my license is
nlallroruamlelfea TI--INTERIOR DEMO
0 �Z License Class Lica
y— Date Muss Pu \ O,V
F�q�¢ ARCHITECTSDECIARATION K/J\
oa u 1 understand my plans shall be Muss public recoNs J
LLita Q- Licensed Prnfeseinnal
y 3 OWNER-BUILDER DECLARATION
he 8<E I herchy affirm that 1 am exempt from the Contractors License Law for the
a 1z0 0 following reason.(Section 7031.5.Business and Professions Code:Any city or county /J
K$� which"after a permit to construct,alter,improve,demolish,or repair any structure
F_} prior it)its isommu.also requires the applicant for such Permit o file a signed statement
i< that he is licensed pursuant to the provisions of the contractors License Law(Chapter 9 Sq. Ft. Floor Area $1090&tion
ofH (commencing with Section 7fXXU.1 Division 3 of the Business a mf Pretoria.Gsde)or
y
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Station 7031.5 by any applicant for a permit subjects the applicants o a civil penalty ofaraC OCCD
not more than five hundred dm11arr(55tH). Occupancy Type
❑I,as owner ofrbe property,or my employees with wages a their sole compensation,
will do the work,and he someone is not intended or offered for sale(Sec.7W,Business
and Professions Code:The Commuc ors License Law does not apply to an owner of 102 - PIERS equlred Inspections
Property who builds or improves thereon,and who dcessuch work himself ter through his
own employees,provided that such improvements are,not intended or offered for at If, 103 - UFER
however.the building or improvement is sold within one you of completion,the owner
builder will have the burden of proving Nat he did not Wild or improve for purpose of 104 — REBAR
sale.). 105 - ANCHOR BOLTS as
rof the property,am exclusively contracting with licensed contractors u' 106 - SEWER & WATER
;�'.smv,l the project(Sec.71MQ Business and Professions Code:)The Counmclnr a Lta net apply man owner of propertywhnwilmnrimproverthereon,and202 - UNDERFLOOR PLUMBING
aruacu Eno.ch projects with a contractor s)licensed pursuant to the Contractor sm Law. 203 - UNDERFLOOR MECHANICAL
mea to ISad. B&PCfar Ix tapen 204 - UNDERFLOOR FRAME
I�te o 205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECOIAiI'ION 301 - ROUGH PLUMBING
I hereby ofnd under penalty Of perjury one of the ta✓✓✓following declarations: 302 - TUB & OR SHOWER
❑I ban and will maintain a Certificate of Cuu
nsano self-insure for Workers Cumpon.
action,as provided for by Section 3700 of the Lair Code,for the performance of the 3 03 - ROUGH MECHANICAL
work for which this permit is issued. 304 - ROUGH ELECTRICAL
❑I have and will maintain Workers Compensation Insurance,as required by Section 3 05 - FRAME -
37M of Ne Isir Cede,for the pufmmence of Ne work for which this permit is issued. '
My Worker's Compensation Insurance carrier and policy number art: 306 - HOLDOWNS 1
Carrier: PolicyNO.: 307 - INSULATION z'-,7
"//��I
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 308 - SHEETROCK
Consection ntadnot beumplcmdifth,permit istomme hundreddellars(SINN) 309 - EXTERIOR LATH
less') 310 - INTERIOR LATH
I certify th m crhad -ce nl the work for which this permit is issued,I shall not 311 SCRATCH COAT
empinyany nymannersn vsmhccomc suhjecunthr Wnr crs'Cn peneatlnn
Liwsmr car am 313 - ROOF NAIL
ANr�N�J1C�] Pok
.TG XPPLICANUE IL of ler making this Certificate t arm Knot you should 501 - FINAL ELECTRICAL ENERGY
MGkrtE subject to the Worker's Compensation provisions of ie1 Led,you must 502 - FINAL PLUMBING ENERGY
Oforthwith comply with such provisions or this permit shall be deemed revoked.
zOCONSfRUCTIONLENDINGAGF.NCY 503 - FINAL MECHANICAL ENERGY
(- Ihemhy affirm that Nen,is a conmmchon lending agency for perrormance of 504 - FINAL BUILDING ENERGY
C > Ne workmaim's ddresshthiapermitisissucJ(Sec.Jl197.Civ.C.) 505 - FINAL ELECTRICAL
Q Under's Name
D z Iendcr'sAJdress 506 - GAS TEST
U O 1 unify that I have read this application and sate Nat the above information is 507 - FINAL PLUMBING
v„r^,
Correct.I agree 10 Comply With all city and county ordinances and sure laws relating to 5 FINAL MECHANICAL
Q building construction,and hereby authnrin mpmsonutiws of this city m cater upon the
C) w about-memionedproperty fnrinspection amends. O9 FIN E
agree In save,indemnify and keep harmless the City of Cupvnina against ag
C4) I rldios,ju ents,costs and expenses which may in any way accroe agaiusl said City 5 N G
U '^ PPnI ANT DERSTANDS 0 the granting if LANhis D WILL COMPLY WITH ALL NON- DIN Issued bys 1 WORKS
Dale
I.
.ATIONS.
1 Re-roofs
wrr of Appliwnt/Crnnmmur vat
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building reeupam sacro or handle hazardous material
as Orland by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
ae.Section z5s3xm7 , All roofs shall be inspected prior to any roofing material being installed.
❑Yes Q]
Will the applicant Or future building secupint use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Dixein't ` �a
C]Yes Com~
e! 61�)
allousmaterialssyuim cors under Chzper 6.95 ofthe Califonnix HSadens 15NI5.335JJ ai 355N.l understand that if the huilding
doesmnant,mar it ix my n,sponsibility my tM rccup of NereyuibemcrprionoissuanceofaCcnificams upucY Signature o(Applicant Dale
Dam - All roof coverings to be Class "B" or better