03040116 CITY OF CUPERTINO + � a ,r,:F:✓dy. �
BUILDING DIVISION PERMIT sCC1NTRACTOR INFORMATION
BY69`0'd"I'ANTAU AVE SYL-MAR CONSTRUCTION PERMIT"°'03040116
° nN 1310 TULLY RD. # 114 PERMrrlsn3T/ 23/2003
WE: (408) 293-7969 SANITARY N0, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
±oo LICENSED CONTRACTOR'S DECLARATION
i 1 hereby affirm that 1 am licensed under provision ofChapter 9(commencing lob Description
with Section 7Msy.f Di ysign Sofmc Busi dPr a ns Codc,andm licenacla
± „ in(wll andefmc j a7 �oZ7�v TENANT IMPROVEMENT
Danns�,�as Come�cay
~ A HI'IECI'S D�Cl.ARATION
E 1u cr J la ell . D public rtaON
G G Licca m caaional
3 OWNER-BUILDER DECLARATION
Contractors
ON
ZM O I hereby.(firm on 11. exempt from the Comamoh License Lew for the
❑o whinwmgremon(Sncittoconstruct,
o L5.Baa;mesaand ve,deomh,orrepirAny aymauure MAY 2 0 2003
$t2i which its requires a permh m lai s the platy improve,h penlieh,or repair any tmWoum
Uzi prion.its issu.ncc,also myuiresthc applicant fonueh permit to Elc asigncJ suumcm
;so that he is licensed pursuant bsthe provisions of the Conuectur''s Lierse Law(Chapter9 Sq. Fl. Floor Area $4�� ion
2s- (commencing with Section 7")ofDivision 3ofthe Bdomeasand PnfassionsCade)or BUILDING
O`i S that he u exempt therefrom and the basis foethe alleged exemption.Any violation of D V G
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penally of 32aP,I`1819f9S 00 Occupancy Type
nos moa than five hundred dollars(5500).
0 I,u owner of the progeny,or my employtta with wages u Meir isle compenutian,
willdotheworkandubswmure is not intended or offered rot ale(See.7W.Bminess 101 - FOUND
and Professions Cede:The Commune,Licu¢e Law dais not apply so as owner of $fid Inspections
property who builds or improves thereon,and who doesauch work himselforthrough his 102 - PIERS
own empinyecs,provided that uch improvements arc not intended oroffersd forule.If, 103 - UFER
however,the building or improvement is sold within one you rfmp
coletion,the owner
builder will have the burden of proving Nat he did am Wild or impmro for purpose of 104 - REBAR .
ask.).
0 1.as owner of the property.am exclusively convecting with licensed conaacoort to 105 - ANCHOR BOLTS
connmm the project(Site7tlaa,Buaimox and Profevomnr Cade:)The Contncmia Lt. 106 — SEWER & WATER
came Law does not apply to in owner of property who Wilds or on pomets therson.and, 202 - UNDERFLOOR PLUMBING
who tartness(or such projects with a cone tctons)licensed puravam to the Commetors
License Law. 203 - UNDERFLOOR MECHANICALm exempt under See.
0 l e ,B&P C for this noon
Data 204 - UNDERFLOOR FRAME
0Owner WORKER'S COMPENSATIONDECLARATION 205 - UNDERFLOOR INSULATION
1 hereby am.under penalty of perjury one of the following decimations: 301 - ROUGH PLUMBING
- IhaseandwillmaintainaCertifcateofConsenuosd6lmumrotWorker'sCompen- 302 - TUB & .OR SHOWER
ration,u provided for by Section 3700 of the Labor Code,for the performm at of the 3 03 - ROUGH MECHANICAL
wall for which this permit is iutaxL
caro and will maintain Worker's Compensation Insurance,as required by Section 3 04 - ROUGH ELECTRICAL
37 o(the Labor Code.for Ne performance o the work fat which this permit is issued 3 05 - FRAME
My Workerk Campers Imanntt t.riera Por yma Wr. 306 - HOEDOWNS
in,
�kV� Pyhe o.: y1 gra 3
CERTIFICATE OF E%EMPTTO FROMWORKERS' 307 - INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
r Icer.)(nit section need not he completed if the permit is for one hundred dullan(SIM) 309 - EXTERIOR LATH
se
1 ani(y that in the perGmmance of the work for which this permh is issued.I shall not 3 10 _— INTERIOR LATH
employ any Meson in any manner u as to become subject to the Workers''Compemation 311 - SCRATCH COAT
Laws of California.Dale
Applicant 313 - ROOF NAIL
NOTICE TO APPLICANT.1[after making this Ceni ricam of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become subject to the Worker's Compensation provisions of the Labor Code,you muse
DZmnhwlmcomply with sixth prwimm.orthisleant,shall be discount mvok.d. 502 - FINAL PLUMBING ENERGY
ZQ MCONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
I hcmhy aMrm that then is a Construction lending agency for the performance of 504 - FINAL BUILDING ENERGY
JJ on,work urwhichlhisp mil isiuucd(Sec.3097.Cly.C.) 505 - FINAL ELECTRICAL
3. Lender's Name
3' 4ndcr's Address
J z 506 - GAS TEST
Q 1 tt agree
duo 1 hese read this application and sate Net the above ws relatium is
cordingIagreeto Comply With all city and countyntatiesof and nu¢lawerupon tl0 507 - FINAL PLUMBING
buildingconstruction,pro and hereby eulborinrpprmemetivm of this city meater upon the
�v ahove.matimned property for imp tdmm pngro es rN - FINAL MEC I CAL
y (we)agree m save,indemni(Y and keep harmless 0¢City of Cupertino against Q 9 F'I
r (n liabilities,judgments u and expenses which may in any way am.ageimt said Cily «v
J z mcomeque ce of
CEO
of perm{L ISSUed b 5 NG Dat O`/
ti APPLICA T U D A DS D WILL COMPLY WITH A NON INT y; C WORKS
SOURC EG NS. ,L
7 Re-roofs
g eofApplicats
HAZARDOUS MATERIALS DISCLOSURE Type of Roof -
Will me applicant or fumes Willi ng occupant store or handle hanotous material
u fined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
C c,Section 25532(a)? All roofs shall be inspected prior to an roofing material bei.
loco❑res �Na P P Y g g installed.
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
,ous air contaminants as refined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yet Xyl.
Heivcmml Wehirard,tore I yvimmcna under Chapmr6.95mfthe Caliur
nia Health&Batt Cod ns 25AI 533 urJ2553a.1 unJcrsmnd muifthe building
dues not cure. y h. a t. in.[ itill my respa moll y m nnfify(be Part of du
requirements ic R emet pnm asuanaof.cenifeamar tt ,nor. Signature ofApplicant Date
n oath. zcJ egcm Date All roof coverings to be Class "B" or better