02120023 CITY OF CUPERTINOrma"• -- �'`•'- - tet.
BUILDING DIVISION PERMIT Re-ONTR�CTbikafNFOIiM�ATI,�ON
BUILDING ADDRESS: PERMIT NO.
t,a:'S NAME: - PERMIT L4 ABARBASANITARYNCONTROLNO,
ARCHI=MNGINEER: BUILDING PERMIT INFO
BLDG ELECT 'PLUMB MECH
3 o 0 - LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 un licensed under provisions of Chapter 9(commencing .lob Description
y IN Section 7qM inrDivision 3 oris B�sandimlessfou Code,andmyliccumbs
.Di u<.11fense e�° 6 (e.• 7 8 781 40.> EXTERIOR FACADE REMODEL/SITE IMPRV
j�'
Data - e caaua f NO INTERIOR WORK
ARCHr1ECi•S LARATION
war. 14 us IJ c_. CONTRACTOR: WILSON AND MARGU�� �c®
MLicensed Professional O5f ,r R b A ti�Ge
p OWNER-BUILDER DECLARATION A q �7
i<f I hereby affirm Nn 1 em accept from dre Contractor's License Law for the FEB 4 [DOJ
0 o following memo.(Section 703L5.Business and Professions Code:Any city or county
5u$tai which ruqulrw a permit in construct,ales.impmm,demolish.Or repair any sumcmm -
Z� prior to its issuance.ala requires the applicant for such permit t0 file a signed attainment 11 A�jyr'��artTf� Q�I1y.�.,
g < that he ie licensed pursuant to the in"isimts of sire conwmor's U...Law(chapter 9 Sq.Ft.Floor Area - .. WONG
y (commencing with Section 7000)of Division 3 of led Business and Profession Code)or Y�L Y{.,'
— that he is exempt therefrom and the bub for the alleged eamption.Any violadan of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of .[1
out come man Bve hundred dollar(M). APN Number $S'lgV*&0y Type
e .
�L u owner or and
property,m m notim yeu wltn vngu u IS=
ale 044.B ZIOUS `
will do ti¢work,ands: swcturelanminLnded Lawddramiepply In a4,Business
ora enywh ore code:Tits COntsulora rad who law area not apply u rt owner car O O Required Inspections'
propenywhO WllNmimproses therton.and whodauucn workhimsslfm through his
Own employees,provided that such lmpm emants are not Intended moRmed for sale.If, 101 — FOUNDATION
howmer,the building or Improvement is sold witbin one yew of compmtion,the owar.
builder will lone the burden or proving that he did not Wild or Improv for purpose of 102 - PIERS
-
sab,).. 103, - UFER
❑1,a owner or the propel•am exclusively contracting with licensed contractors to
comwct the project(See.7001.Business and Poefuslons Cade:)The Conuacmr's Lb 104 — REBAR
ecom Law doca not apply to an owner of propOrty who Wilds or impmm thenum.and 105 — "ANCHOR BOLTS
who contracts for such projects with a conhator(0 licensed purswnt m the Conommes
License law. . 106 - SEWER & WATER
smemmptunder Sec .B&PCrmddaimmon
202 - UNDERFli00R, PLUMBING
ta
WORKERS COMPENSATIONDECLARAnoN 203 UNDERFLOOR MECHANICAL
I hereby strum under pemlty or perjury one of the following declarations: 204 — UNDERFLOOR FRAME -
IhawandwillmaintainaCanifiwmofComethma161nsweforWorkersCompen. - 205 — UNDERFLOOR INSULATION - -
atlon,a provided for by Section 3700 of the labor Code.for the performance of the �301 — ROUGH PLUMBING
work for which cob permit is Issued. . .
❑I lure and will maintain Wmkerk Compensation Insunmm,as required by Suction 302 - TUB & OR SHOWER'
3101. the U1WrCWc.for the performance of the work for which this pcoralt is lsdmd. 303 . - ROUGH MECHANICAL
My rkcr' ROUGH ELECTRICAL
Coii..Z.lonlnsmaaeearrimand Ilcynumberare: d '304'" -
er.3?A'A'ft Fwo'D -�ry�I�/f{/'bNo,: ISY7 '3Raf. t -
CERTIFICATEOFEXEMPr1ONFROM WORKER wtJ e3 305 = FRAME - -
COMPENSATION INSURANCE /� - 3 0 6 — HOLDOWNS
nr bas.)
(This seal.need not he mmplemd if tion punch b for one hundred dollars(glm0 307 - INSULATION
' '
I certify That in the Performance of me work for which this permit is LLewe,1 shall not 308 — S HEETROC K""
employ any person in any manner an u in become subject to the Workers'Compenaadon 309 EXTERIOR LATH
Laws of California.Date
Applicant 310. -` INTERIOR LATH
NOTICE TO APPLICANT.If,after making this Cenificam or Eamptiun,you should 311 — SCRATCH COAT
become subject In Inc Worker's Compensation provisions of the labor Code,you must - -
.J Z forthwith comply with such provisions or this permit shall be deemed revoked. 3 13, — ROOF NAIL -
zO CONSTRUCTION LENDING AGENCY 501 - FINAL ELECTRICAL ENERGY
(—� I hereby aRrm that mere is a construction lending agency for the performance or - _
C?„ the work for which this permit Ismwd(See 3097.Civ.C.) 502 . FINAL PLUMBING ENERGY ,
Dp Lenaer'aName 503 FINAL MECHANICAL ENE
a+ Iandmi Address
]z 504 FINAL BUILDING ENERG
p I coolly that 1 have mad this application and atam the[the ebom mmm,atmn 1" 505. - FINAL ELECTRICAL
Cicer' correct 1 agree to comply with all city and county ordinances and sum laws¢bring to
) building construction,and hereby auhoriza reprommatios or this city to enter upon the GAS EST
W ahovcmentioned property for Impaction purposes
y (We)agree to save,indemnify and kap humlea the City of Cupertino against O 7 F I
N at---la,ji-ted judgments. and expenses which may In any way accrue against aid City CJ AL 27U 7 In co mote ofthegranting ofThispermit' APP' UNDERSTANDS AND WILL COMPLY WITH ALL NON.PDINT Issued by:5 Da
RIC GULATIONS. ,/
»-
?� e NAL PLANNING
Q C jC G�/ .3 Re-roofs 7
Signaurecf AppllmH/ConnRDOUSM RIALS DISCLOSURE 'Type of Roo t14 - INAL PUBLIC- WORKS
Will the applicant or future Wilding occupant mom orhandle hvwdous material
mrd hY the CupeNno Muniei 1 CDde.Cbapmr 9.12,and the Hulce and Sarety '
0y.zss3z(.)7 All roofs shall be inspected prior to any roofing material being installed.'
❑rid No .
Will the applicant or future building«wpant'ox eq ulpmem or devicee which If a roof is installed without first obtaining an inspection,I agree to remove
7�q*k,
hazardous air conlaminanIs as fined by the Bay Area Air Quality Management' all new materials for inspection.
Nu
I have reed the huardwsmamrials eptiremenu underClespmr6.95 ofthe Olifor.,
eslth&SafctyCOdc.Scctiow25305,25533and25534.1uMcnunathulfdc WlWing
Signature of Applicant Date
ur.omurie..ed asent Dam - .. All roof coverings to be Class "B" or better