02120083 CITY OF CUPERTINO '��• ' "'v "" -
BUILDING DIVISION PEFMT W-ONTRACT�;OR41NFORNIATION:
BUIIAINGADDRESS: - PERMIT NO02120083
OW OWNERS
NAME: � ��(J(�" 8/2003
SANITARY N0. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t� t�
300 LICENSED CONTRACTOR'S DECLARATION Job Description
F 1 hereby aRinn Nal l am II.Ned under provisions of Chapter 9(commencing P
with SeNon Taft (Division Bnf aro Business and Promisous Code,and my license is
m full tome and effxe
License Class Lm.g TENANT IMPROVEMENT (1936 SQ. FT. )
1- Dam Conuanor
nq ARCHITECTS DECLARATION
f�uuZZ I Professionand al PIaN shall he uaetl u public rtcnNs I`
6 1/ \\\
ao Licenced Pmfcssional
kg OWNER-BUILDER DECLARATION
2 O y 1 beteg affirm(Section n I am exempt from me Goths Co License Law for tbe
po followingmason. eitt7onsu ttinestand Improve.
professions Coda:Any city or county
COO
fi which mquims a issuance.abil re ennsnmet.alley,hnpmw,deermitt ar rtryig ed tatement
prior m its ensedpalso pursuant
to IN the applicant for such permit m Ole a signed statement
-imat he is licensed Purmanlmtbc pmvisiaN of dee CanllxemfrlJ.nas IJW(Chapter 9 Sq. Ft.Floor Area Valuati
I15p (commencing with Section 701 of Division)of me Business and Profcaaions Code)or
R 8 that he Is exempt memfmm and the basis for the alleged exemption.Any vlolatfon of
Section 7031.5 by any applicant for a parmh subjects the applicant In a civil penalty of APN Number ,� y Type
not...Nan five hundred dollen(5500).
❑I,w wnerof Nepmpeny,ormyemployeuwiNwpsutheirmleeampenudon,
will do me work,and Ne fracture is notimmnded or offeredrondo(Sm.7M4,Business 3 5 7 1 7 UT=URequired Inspections
and PmfesdoN Code:The CmaracmYs Lt.-law duet set apply m an a..of
q P
property who Wildsorimproves thereon.and whodocaauch work himselfor through his
awn employes,provided met such improvements are not Intended"offered for ask.IL 101 - FOUNDATION
however,me building or Improvement is sold within ane year of completion.me owner.
builder will haw dm wrath of proving m
iat he and not Mid or Improve for purpose of 102 - PIERS
sale'' 103 - UFER
❑1.as aw.r of dm property,am exclusively conuactmg,wide licensed emormuss m
Construct on,pmjen(Sec.7014,Business and Professions Code:)The Con racmYs U. 104 - REBAR
cease Law does not apply m an owner of property who Wilds or improves mamas.and, 105 - ANCHOR BOLTS -
whocantnemforsueh jcps beim a eonuacmr(s)licensed punusnt to ON Conuuno's
Lkenas law. 106 - SEWER & WATER
pIan Oempn _ ,BhPcmr thin n 202 - UNDERFLOOR PLUMBING
Owner Dam 203 - UNDERFLOOR MECHANICAL
ORKER' COMPENSATIOND• ON
I hereby affirm under Penalty of pedury ON of th awing declarations: 204 - UNDERFLOOR FRAME
I haw and will mainuin a eeriliNm of Consent m self-Insure for warkeraCompn- 205 - UNDERFLOOR INSULATION
calian.as provided for by s.don 5700 of the laver code,far the prar forou me, 301 - ROUGH PLUMBING
work ser which this pork is issvea. 302 - TUB & OR SHOWER
❑1 can and will maintain Worker's Compensation Insurance,as requited by Schon
37Mofthe Lainrcode.far me peg....of me workfar which this prmkmhood. 303 - ROUGH MECHANICAL
MyWorkefsCompensation[..a.Orrin and Policy number em: 304 - ROUGH ELECTRICAL
Carrier: Policy No.: 305 - FRAME
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 306 - HOLDOWNS
Ohksection need not becompleuvl iftbe permit is forme:hundred dollN(S10D) 307 - INSULATION
arenas) 308 - SHEETROCK
I«nlfy manor rn ay or me work for whis m' permit' iu.d.I shall not 309 - EXTERIOR LATH
employanypers t ermasmbecomeN ct .� mpnastlan
Lawaof CaOmm . 'l 310 - INTERIOR LATH
Aplin an
NOT AP A :If.alrmakingthisCariOcamofExempton,youshnuld 311 - SCRATCH COAT
beco a subject m me others CompNation previsions of dee Labor Code,you mut
7zmnhwimcamply with such provisions or this permnshall be d.med mwked. 313 - ROOF NAIL
z CONSTRUCTION LENDING AGENCY 501 - FINAL ELECTRICAL ENERGY
Imalty affirm that means isaeombucdnnlending agency rormeperemua.or 502 - FINAL PLUMBING ENERGY
Y> lhawork Narnat ddspemitmp.a(seeBan.Civ.c.) 503 - FINAL MECHANICAL ENERGY
37 0 Leaders Name
j z anae;.Aaaes 504 - FINAL BUILDING ENERGY
J Q 1 certify that 1 have mad this application and sum that the above information Is 505 - F I NAL ELECTRICAL
y F cotmet.I agree to comply with all city and county oNinances and sum laws totaling to
pU building conswction,and hereby othonzerepmmnmivesofthis city menmrupon me GAS TEST
C above-mentioned property for inspection pugmxes hQ F I
y (We)ago.to cave,indemnify and kcep harrow 0.City of Cupertino against
Vtl
fq 0milides,juagmcnta,coca and expensOwhich may Inany way amucagainst said City A C ICAL
t7,z in caNequence of ting of this permit.
^� APPLICANT D ANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOUR _
Re-roofs 514D"Lu INAL PUBLIC WORKS
Were plicanVConuanor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof '
Will dee sppli.m or forum Wilding o.upant Wore or handle hoodoos mamnal
u defined by rte Cupertino Municipal Code.Chapter 9.12.and the HOIm and Safety
oac.QYu 23552(x)? �Na All roofs shall be inspected prior to any roofing material being installed.
Will me applicant or mmro building..pam oxe equipment or devices wMgA If a roof is installed without first obtaining an inspection,I agree to remove
haroranus air contaminants u dcired by the Bay Arca Air Quality Management all new materials for inspection.
iurict7
❑Yes t7(I Nu
I have mptl M hondousmaterisls mquiremeto unser Clupmrb.95oflhcCaliror-
niaHwINRS 6=25505,25533 vol ZSSN.lundersmnd revs if me wilding
docs u a a ant.that it is my responsibility m ratify ar the
mqui me tw etpdormmu mooracenantlfmaca F �j ignature of Applicant Date
wncr orauthorigcaagcm Dam All roof coverings to be Class nBn or better