02110025 i
CITY OF CUPERTINO
BUILDING DIVISION PERMIT ;CONTRACTOR INFORMATION:
BUIL�10O(�$ si`0 STEVENS CRK W L BUTLER INC PERMITNfp2110025
ISOY EPROPERTIES 204 FRANKLIN ST nrrucAnsJO ('2002
410NE: (650) 361-1270 SANITARY NO. CONTROL NO.
ARCHI'fEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
foo LICENSED CONrRACTOR'S DECLARATION
� . 6n
p 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing REVISION--IN 81J5cr�S ONLY
zw with Section 7001q of Division 3 of file Business and Profession..,Code.and my iii case is
<n• morn force a ad effect. EXTER. LIGHT REVISIONS, NO NEW PERMIT ISS
~n= License Class Lie.#
F?_O IDam C,Imraatnr ORIG. #02010086
ARCHITECT' nrcLARATION
< 1 understand my plans shall W used as public mcmdx
p6V O
ui3 a�
Licensed Pnnlcsxinnal
=OS OWNER-BUILDER DECLARATION
yK s p hereby auirm but I am exempt from the Contractor's Manu Laws for the
m 600 following reason.(Sermon 711J 1.5.Business and Pndeuinnx Gde:Any city m county
e R$� which rtyuiras a permit hr amsruct,alrer,improve,demolish,or repair any urocrore
ad--Ot prinnn its issuance,also requires applicant forsuch Permit to file a.aigned statement
EFS that he is licenWd pursuant to the provisions of the Contractors Licen¢Law Zapter9 Sq. Ft. Floor Area $20V00tion
C— (commencing with Section 71%)(1)(11 Division 3 of the Business and Professions Code)or
i 3$ that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a peormi subject the applicant o a civil Penalty of e Occupancy Type
not more Nan Tiw hundred dollars(S500).
❑L us owner of Ne progeny,n my employees wish wages[Inch ante cam I cation,
will do the work,and the structure is not intended or Offered for sale(Sec.71104,Business
and Profcesiom Cock:"no,Contractors Limn.law does not apply to an owner of 10 2 - P I ERS egwred Inspections
progeny who builds or improves thereon,and whodoes such work himulf or through his
own employees,provided that such improvements are not intended or Offered for sale.If, 103 — UFER
bowever,the building of improvement is sold within are,year of mrapichim,Ne owner 104 — REBAR
builder will have the burden of proving Nal he did not Wild or improve for purpose of
saleJ. 105 - ANCHOR BOLTS
0 1.as owner of the progeny,am exclusively contracting with licensed contractors to 106 — SEWER & WATER
construct the project(Sea 7844,Business and Professions Code:)The Contractor's Li.
cense law does not apply In an Owner of propeny who Wilds or improves thereon.and 202 - UNDERFLOOR PLUMBING
pL.m.cwt for such projectsprojectsu
with acomnmrts)emx
c, ca pursuant to fee mmn
e Coor'aL . 203 — UNDERFLOOR MECHANICAL
l am exempt under Sec. ,B&P C for his reason 204 - UNDERFLOOR FRAME
wacr Date i 205 — UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION 301 - ROUGH PLUMBING
I hereby affirm under penalty of perjury One Of the following declassiois: 302 — TUB & OR SHOWER
I have and will maintain a Certificate of Consent n self-inmre for Worker's Compete
salion,as provided for by Sectio 3700 of the Labor Code,for the pemmmamale of t o 3 03 — ROUGH MECHANICAL
work for whichthispmanisissued. 304 — ROUGH ELECTRICAL
Fl 1 have and will maintain Worker's Compensation Insurance,as rcyuired by Section 3 05 — FRAME
3700 Of the Labor Code,for the scullmmanm of the work for which this permit if iomd d.
My Worker's Compens2inn Insurance carrier and Policy number are: 306 - HOLDOWNS
Carrier: P(1RcyNo: 307 - INSULATION
CERTIFICATE OF EKEMPr10N FROM WORK ERS' I
COMPENSATION INSURANCE 308 - SHEETROCK
(Thiswcomanced notWcompleted iflW permit iiforanc hundred dollars(Strait 309 - EXTERIOR LATH
Or less.) - I 310 - INTERIOR LATH
1 certify that in the performance of the work for which this permit is iasued,I{mall am 3 11 — SCRATCH COAT
employ any pcmm in any manner so as to Become subject to the Workers''Comjmnsatnd,
Laws ofCaldoom..Date 313 - ROOF NAIL
Applicant I
NOTICE TO APPLICANT:IL after making this Cenifiexto of Exemption.yob should 501 — FINAL ELECTRICAL ENERGY
Wrome subject to the Worker's Compo azation provisions of the labor COR.you most 502 — FINAL PLUMBING ENERGY
Z forthwith comply wilb such provisions nr this permit shall W deemed revoked.
z0 CONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL ENERGY
[-. .N. Ihcnhy alSirm Nm there isacanswaion lending agency fur perlimmsnce in 504 — FINAL BUILDIING ENERGY
a > the work for which this permit I.issued(Scc.300)7.Co.CJ 505 — FINAL ELECTRICAL
Wo lender's Name
0. Lead,,',Add.,, 506 — GAS TEST
UO 1 ceNfy that I have read this application and sell,that the about information is 507 — FINAL PLUMBING
W F
Correct.I agree to comply with all city and county ordinances and slate laws relating to
bmdamg c(1nswetmn.and hereby amthnri.e reprmemmma.,(1r wx,hymem,r mp(1a me 5 FINAL MECHANICAL
�� abow-memiOoed properly for inspection purposes. 09 FIN (� EA
(We)agree it)saw.indemnify and keep harmless the City of Cupertino against
rfaq liabilities.judgments,cost and expenses which may in any way accrue agmnsxaid City 5 �N G
CJ Z in cnnuyucnce of the graming of Nix permit.
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON�POINT Issued by-5 WORKS Date
SOURCE REGUI.A'1'IONS.
Re-roofs
Signator,Of ApidicantlContractor Dale
HAZARDOUS MATERIALS desuloottore or URE Type Of ROOF
Will y t applicant or future building occupant slam or handle hvarduus mamdal
az JcfincJ by the Cupertino Municipal QdC.Chapter 9.12,and the Health and Safely
Code.Seedon 2s5321a)7 I All roofs shall be inspected prior to any roofing material being installed.
OYe., ❑N(1
Will thea Ecam(1r mtumbuildin occupant sex„ mi ,nlserd,ri,cswhich If roof is installed without first obtaining an inspection, I agree to remove
pp d t pan 4 Pm
emit ic,? aux air contaminants az JdineJ by the Bay Area Air Quality Manascmcnl all new materials for inspection.
Disvinf
[1)Yet, 0N
I have real Ne Wood...smateriaHnyulrement under Chapter 6.95 of the Callhrc
Diu Ilcalth&Sandy Crslc,Sccunns 25A15.2553J md255JJ.I understand Nand IMS Wilding
diva not currently haw a Waanl,that it is my responsibility
to autily t W scup i t OI the
rtyuinment which muslMmcl pdono isuancc ofa Cenificareof Q'cupancy Signature of Applicant Date
Owner onauthowdagent All roof coverings w be Class"B" or better
i I