03060081CITY OF COPERTINO
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BUILDING DIVISION PERMIT
CONTRAcRINP'OR�MATIQN
.
BU I LDING ADDRESS:
SCOTT ARCHITECTURAL GRAPHI
?""GD3060081
R'SNAME:
12%5 N. DUTTON AVE.'#4
l�"r`r"'97.0/2003
Py'E
E:
(707)545-4519
SANITARY NO. CONTROL N0,
ARCHMICT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACT'OR'S DECLARATION
Chapter 9
Job Description
o
provis s of (commcndng
I am licensed under provisions
1 hereby affirm Nn und
with Section 7M of DiAs.. Sof the Business ProfcWuns Code, and my licenso is
Lrnllf.ne Gp31.k�g 3
Lkcnc
REVISION --IN HOUSE USE ONLY /
D ee G°^
ARC DECLpc ION
NO NEW PERMIT, ORIG. #03030028 \0S
all M used
1 understand my plans shall W used u public mcoNs
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Licensed Pm(cssiond
OWNER -BUILDER DECLARATION
1 herchy affirm that I am exempt from the Convector's License Law for the
following reason. (Section 7031.5, Business and Professions Code: My city or county
which mgWnu • permit to ronsuucL alar. improve. dem.luh, at repar any atrecturc
prim to its issu°"¢. atsu requites the applicant fmwch permit to file. signed comment
mal M is licensed pursuant to rise provisions ofthe Convecwrs Luxose Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and ProlesslonlCMe) or
0
that he u mrso pt therefrom and the basis fm the alleged exemption. My violation of
APN Number
Occupancy T
P y y�
Section 7D3 L5 by any Applicant for a permit subjects the applicant to a civil penalty of
mot
not e then five hundred dollen (5500).
36901028.00
01, sae ownerofthe property, mmyemployees with wagesutheirsokcompensation,
d Inspections
will Oct de wod: and the suucwrc Is not mAmdeA m offered for sale (Sec. 7044, Business
and Professions Code: The C.nuactor's License Lew does not apply to an owner ofyp��ygl
property who Wild co improves thereon, and wMdoesamh went throughhimself., ough his
101 — FOUNDAI IVH
own employees. provided that such imponamens Am not inended moffued for tele. If.
103 — UFER
Wwewr. the Wilding or improvement is told within one year orecordation, the owmr.
builder will brow the Widens of proving that he did wt Wild w improve for purpose or
104 — REBAR
"le''
105 - ANCHOR BOLTS
0 1. as owner of the property, am exclusively com acting with licensed convectors to
comWet the project (Sec. 7044, Business and Professions Cade:) TO, eontnctor's Ll-
304 — ROUGH ELECTRICAL
cense law does not apply to an owner of properly who builds or Improves Hereon,and
505 - FINAL ELECTRICAL
who contracts for such projects with s comActor(s) licensed pumam to the Con=toes
'
License law.
514 - FINAL PUBLIC WORKS
0 1 ata exempt under Sec. . B k P C for Nis wan
Dow
WORKER'S COMPENSATION DECLARATION
I hereby grim under penalty of perjury one of the following dalendons:
'he
E0 1 hew and will mmmuln a Cen ficateofComMu W aelbWurc fm Woks's Compere
ns provided for by Section 3700 of the labor Code. for du pmfonnsnec of the
work for which this permit is Issued.
❑ 1 have and will maintain Worker's Compensation Insurance. As required by Secdan
37M of rite labor Code, for dm performance of the work for which this permit is issued.
'
My WmAccea Comp me don Insurance canner and Policy number am:
C° r.2�0&IC l�lV'4d1TI Polity .. Q/
CERTIFICATE OF B%EMPnON FROM 0 ERS'
COMPENSATION INSURANCE
('Ibusccdon need not W eemplcted If the permit Is (mere hundred dollars (5101)
or less.)
I certify that in to Mr.... of the worts for which this permit is issued, I shall not
employ my person In my manners, As to become subject In dC Worker Compensation
Law s of California. Date
Applicant
NOTICE TO APPLICANT: If. afmr making this Comfleate of Exemption, you should
bcrome aubjmt to the Wooer's Compensation provisions of ted labor Code. you must
foMwi th comply with such provisions or this Permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that dere is a ronswction lending agency for the Performance of
the work fur which this permit Is iumd (Sec. 3097. Civ, C.)
Uncles Name
LA.dmes Address
m that the Move information Is
I certify that I how read this application and show
'
corem and to
cereeL 1 °gree w Comply all city Ntl County omkes
hwithere representatives of this city to soar upon the
and hereby aundodm of city to rat r upon
building construction,one
aM1ove-mentioned pmfor WPecdan purposes.
to.. hop ha.
(We) egme to taw, indemnify and hop harmless rite City of cupenst against
expenses which may In my way acrncagelnR said City
v�
in consequence
in conxgmrme.f the Bunting.( this permit.
of the
(CANT UNDER NOS AND WI COMPLY WITH ALL NON -POINT
'//_7
Issued by: Date
R GUL 0 S
Re -roofs
Type of Roof
11) 03
is. unt-61Appliem,10cmilosom Dow
HAZ RDOUS MATERIALS DISCLOSURE
Will the applicant., (mum building accupmt atom or hanJle hmardous meurial
as de0ned by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
c,S-]Yeson 35532(e)? N
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
r town
Will the applmxul se eq
Wilding occupant Am or devices which
..It havuNons air roan inmu u defined by the Bay Arca Air Quality Management
all new materials for inspection. -
District?
D Yca Nu
I h&Safat
Code, d..n5dalsrcquiremenuonderChapkWUmifhcCilifm-
Wilding
doesMn,unnodyhavec,Sn. atilt25533and25534.1wrodlntldistifdm
docsnot cunendy howa suns N ohk mjnce omihilitytonadfydaoccupant of the
myuirc 'ch R met ri.rtoissumce.nemtifiese.rOccupancy .
Signature of Applicant Date
Q
All roof coverings to be Class "B" or better
owner.,,
th.ded sag t Da/�