03080112 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRAGTORINFORMATIO,N
BUILDING ADDRESS: CONSTRUCTIVE BUILDING SVC, P?LnFQ03080112
�Qn STEVENS GREEK BTMVD
.R'S NAME: 3937 39TH AVE PERMIT ISSUE DATE
nAy CASEEIREP MADRID RATCHET-DER 002
NE: (510) 531-1175 SANITARY CONTROL NO.
ARCHITECfIENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
00 LICENSED CONTRACTOR'S DECLARATION JobDescri tion
here m @m 1 am licensed under provisions or Chapter 9(commencing P
m with Section] ivision 3 of NC Business and dL.ad aei4rmacis
,qz Liana) a TI--LAW OFFICE (SUITE 450
PINALED0
Date Cumrecmr
A TELTA
a ndcrstanJmyplansshellMusctle lid JAN 2 g 2004
6
s,t; Licensed Professional
a S OWNER-BUILDER DECLARATION
<I 1 hereby affirmsct that I am exempt from the Contractor's o License Law for the BUILDING.p O following massa Permian 7031.5,Business and improve.
dcrions Code:Any city or rounty Bi U
$ which requires a permit na construct,elreq improve,Jcmnlish,or repair any.gructuro
triton itsiensedp pursuant
re quites thovisio sof for Contrarmiuoicense ave(Chapter
cm
sza that me cing with Section
70th)of Division
of the eBusinesssnd Professions
(C ode) 9 Sq.F[. Floor Area Val shoo
Z F p met he ise(commencingxempth Sectiourn and the
Diaiii°n 3 the
the Business and on.Any
Code)or
of
Net he is exempt themfmm and the bazis for Ne alleged exemption.Any violation of
Section]03I.S by any ep,lic.,for a permit aubjccu the applicant to a civil penalty of APN Number Occupancy Type
not mom than five hundred dollars($500). P Y YP
❑I,az owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.70".Business 101 -uFOUNDP.[$e�QpTd Inspections
and Professions Code:The Co men 's License Law dons not apply to an owner of
property who builds or improves thereon,and who docs such work himadfar through his 102 - PIERS
own employees,provided that such improvements are not intended or offered for sale.If, 103 — UFER
however,Ne building or improvement is sold within one year of completion.the owneo-
builder will have the burden of proving that he did not build or improve for purpose of 10 4 - REBAR
sale.).
C]1,as owner of the property,am exclusively contracting with licensed contractors to 1 05 — ANCHOR BOLTS
construct the project(Sec.70,14,Business and Professions Code:)The Convmcom''s U. 106 — SEWER & WATER
me law docs not apply t0 an owner or propeny who builds or improves fiction,and
who contracts for such projects will a c0onswor(s)licensed pursuant to the Convectors 202 - UNDERFLOOR PLUMBING
License Law. 203 - UNDERFLOOR MECHANICAL
❑I am exempt under Sea ,B&P C for this reason
204 - UNDERFLOOR FRAME
r ole
WORKERS COMPENSATION DECLARATION 205 - UNDERFLOOR INSULATION
I hereby affirm under penalty of perjury one of the following declarations: 301 — ROUGH PLUMBING
(have and win mainwna CerdfemanfConmmmulf--maim mrworker'aCumpen- 302 — TUB & OR SHOWER
cation,as prodded for by Section 3]00 of the labor Code,for the performance of the 3 03 — ROUGH MECHANICAL
work for which this permit is issued
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3 04 - ROUGH ELECTRICAL
37W of the labor Code,for the performance or the work for which this permit is issued. 305 — FRAME
My Work C pe i 1 i)r end Palmy" 306 - HOLDOWNS
Ca 'er 'CERTIFICATE OF EMPI'IONy No ORKEERRS'' 77 307 - INSULATION
COMPENSATION INSU NCE 308 - SHEETROCK
or lcscJ(This section need nm he completed if the permit is for one hundred dollars n IW) 309 - EXTERIOR LATH
1 certify thin in the performance of the work for which this permit is issued.I shall not 310 INTERIOR LATH '
employ any Person in any manner ss as it)became subject to the WorkcrCCompcnsation 311 — SCRATCH COAT
Laws of Califomia.Datc
Applicant 313 - ROOF NAIL
NOTICE TO APPLICANT If,after making this Ccnifcste of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
hccome Subject to the Workers Compensation provisions of the Lahor Cndc,you must
�0 forthwith comply with Such unwomm or this perm its hall be accrued newkca. 502 — FINAL PLUMBING ENERGY
ti h CONSTRUCTIONLENDING AGENCY 503 - FINAL MECHANICAL ENE Y
afford th
I hereby afford there is a construction lending agency for the perfuromoc of 504 - FINAL BUILDING ENE
X to work for which this Permit is issued(Sec.3097,Civ.C.)
' q Undef'aName 505 - FINAL ELECTRICAL
z Lender's Address
Q I certify that 1 bout read this application and Stam that the above infoommiun is
506 - GAS TEST
y en.M.I agree to comply with all city and county ordinances and state laws relating l0 507 - FINAL PLUMBING
building construction,and hereby aothmiac roprescmatives of Nis city to enter open the
�U above-mentioned pmp)ny for inspection purposes. FINJ&NG
CAL
tiG (We)a to save,indem y and keep harmless the City of Cupertino against 0 9 FI
jV] liehilitiea,j me ,c nseawhichmayinonywayaccmcagainst veld City
in con w one of f is pe-mfl. 5
APPLANT ER N AND WILL COMPLY WIT - ssued by:5 WORKS Date
SOU CE ATI S. D
Re-roofs
5 Si nelu ant or Date
caul OUS MATERIALS DISCLOSURE Type of Roof
It plipon! arum builIing ode,Chapter
em handle Health
rdhns material
andSfety
u io a 32(a)? Manic 1 Code,Chapter 9.12,and the Hcal@ and Safety
otmnzssu(°)+Yes No All roofs shall be inspected prior to any roofing material being installed.
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
it haiammus air contaminantstkfined by the Bay Arca Air Quality Management all new materials for inspection. -
isvict?
❑Ycs No
1 d smaw,ials undo-Chapar 6.95 ofthe Califon
ma" N& tits , 5533and25534.lundcrsund NatifNcbuilding
dnot c c n4 Nat it is my responsibility in non y the occupant 0
r nim ust melpunrlmismananfaC ¢E c y 4. Signature of Applicant Date
Ow rora -sed nt %� Dam All roof coverings to be Class "B" or better