03060117 CITYOFCUPERTINO TT��TY�a11ka,,��T LryAm'yyyy�*,k2,k'��^•s //�y� rr{� `�Ia,�,kr�
BUILDING DIVISION PLl�1Y11T '�Il.v� .l�[7sCVR 111.0ORMA.' 7U1 ;
BUILDING ADDRESS: F C HO PERMIT NO.03060117 3060117
OWNER'S NAME: PERMITEsU gA717/2003
SANITARY NO. CONTROL NO.
ARCHITECTYENGINEE'R: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Sop LICENSED CONTRACTOR'S DECLARATION
die VF�,j I itmby Nims met I am licensed under provisions of Chapter 9(Commencing Job Description
n X1E with Section 7070)of Divided 3 of the Business and Profession Code.and my liceme Is
S in full fame and effect
License am g REVISION--IN HOUSE USE ONLY
I_ Dots contrxvdr NO NEW PERMIT ISSUED, ORIG. 303010042
ARCHITECTS DECLARATION
U 1 un&=ad my Plana Nall he used as public records
a u.O t; Licensed Profrstidnal �\
Oat I am exempt
U rpt from
DECLARATION
COO Mmhy.(firm that1I. a Business
faro Ur Conorm Co :Anse claw for the
5 COO following muaa(Section Rnsu r. . and ver,emoli Cade:Anycity structure S
$ which requires a permit m cnmtmet eMt ha Prove,demolish,m e a sign d structure
-zi
prior to its isuanm.aWl requima lM applicant for such permit to Ole aaigwtl statement
< thatheislicensedpursuantwlMprovisiomoft oConmweiUmme, aw(Chapter9 Sq. Ft.Floor Area uation�
F,
$ (Commencing wit Section 70M)of Division 3 of CO Business end Protections Code)or
But he Is exempt themfrom and the basis for the alleged exemption,Any violation of - 0
Mallon 7031.5 by arty applicant for a permit subjects du applicant to a civil Penalty of APN Number Occupancy Type
not mom Nen five hundred dollars(5500).
❑I,uowmraflM propeny,mmy cmplaYce with wagssutMir sale Compewtian, 35717012 ' 00
willdo the work,and Nemucwm is not intended oroMendl Image(Sec,IDN,Business Re 1 dlDs actions
and Proposed.Code:The Camseme.License law does not apply w an net of T p
property who Wilds or im proven Common,and who dos suc h work him sel f ar through his ��
101 — FOUNDA
Own employee,provided that such Improvements are not Intended oraffered ferrule.IC 102 - PIERS
however,to building or improvement is win within can year of Completion,the owner.
builder will be"de,traded of proving Net he did not build or improve far purpose of 103 — UFER
.in.). 104 - REBAR
0 1,es owner of IM property,am exclusively connecting with Imemed contractors to .
cnMrat Be,project(Sec.7044,Business and Profcadae Code)The Condwwr.Lt. 105 - ANCHOR BOLTS
"me Law doss not apply to an owner of property who wilds or Improve Overton.and, 106 - SEWER & WATER
who contracts for such projects with acontncmr(s)licensed purwam on the Comrawra
Lmenrelaw. 202 - UNDERFLOOR PLUMBING
01Wt exempt rsec. B&Pc frthhreasan 203 - UNDERFLOOR MECHANICAL
Dow%' `�'°e t 3 204 - UNDERFLOOR FRAME
WORKERS COMPENSATION DELLA ION
I hereby affirm under penalty of Perjury we of dive following decimation: 205 - UNDERFLOOR INSULATION
ve and will maintain
a Carificam mc.msenu.self-imam for Worker.Compm- 301 ROUGH PLUMBING
n,as provided for by Section 3700 of do,labor Code,for the performance of Ove 302 - TUB & OR SHOWER
work for which this permit Wood. 303 - ROUGH MECHANICAL
0 I have and will maintain Worker's Compensation Insurance,u required by Section
37M of the Labor Count,for the performance of due work for which this permit is lsued. 304 — ROUGH ELECTRICAL
My Worker.Compensation Insurance arricr and Policy number am: 305 - FRAME
Carrier. Policy No.: 306 - HOLDOWNS
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 307 - INSULATION
(ThuseNan nand Out M completed ifthe Permit isfmdm,Whdreddaltsn(5100) 308 - SHEETROCK
1In.) 309 - EXTERIOR LATH
1 unify that in the performance of the work for which this permit Is handed,I hall not 310 - INTERIOR LATH
employ any person in any manner w as re become subject to to Wortmor Compemadon
Iawaof Cellfdmte,Dave 311 - SCRATCH COAT
Applicant
NOnCE TO APPLICANT,If,am,making Iia Cenifictm of Exemption.you should 313 — ROOF NAIL
become subject to the Worker's Compensation provisions of the Labor Cede.you most
�Z rorlwith comply with such provisions orthis Permit that Mdevoted cooked. 501 — FINAL ELECTRICAL ENERGY
z CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
I herby affirm Wt themisa eommuctina kndingageray for the perfmmancc of 503 - FINAL MECHANICAL ENERGY
Y> thCwork for which thtsPermit Isissued(Sm.3097,Civ.C.)
Lender's Name 504 - FINAL BUILDING ENERGY
y Q
jZ endr1Addmu 505 - FINAL ELECTRICAL
i certify Tat I banply mad Iii application and mo Net IM above"MIAU02 ts 506 - GAS TEST
1 U conett I agate w comply with all airy and county t1 ordinances and some laws relating m
7 O wildmgutdo"dtiro and heron authonp rposes utivss Of IMS city to enter upon Ove FINAL PLUMB I G
N a awve-(We)age Property for impaction keep ha 0 8 F I L
e,ju agree to cove,indemnify and tech hay in m the y re of ruCupertino against
Z in COnwquxdgmcnts,costs andnif expenses parrothmay in my way¢true against City I
J z A APPLICANT
of the{mating of this parrot
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINTIssued by:5 NG ORKS Date
SOURCE REGULATIONS. _
tgnmurc of ApplicandCanuwroe-roofs
r - Dm
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future wilding occupant store or handle h mardom material
u defirod by the Cupertino Municipal Code.Chapter 9.12,anal IM Health anal Safety
We.Section25532(a)?
6�a All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future wilding Occupant uan equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
harardnus air conuminanu defined by IM Bey Arca Air Quality Managemem all new materials for inspection.'
jet?
❑Yes Nu
Hit maJ the henardnusmamriale mquircmcnu unticr ChoPmr 6.95 of Ic Califon
nice Heall4,Safmy Catic,Seetio.25505,25533.4 2534.1 undcrsund Ise if the wilding
docs not currently Mw a unenL Nat h u my respo.ihilhy w notify Ove mcuPant of Ie
reyulremcnuw ' muuMmupriorwiasuanccofeCcnificamofOccup r ignatureofApplicant Date
er or aatwrivea sen, De/ All roof coverings to be Class "B"or better