03030151 CITY OFCUPERTINO reg'.«
BUILDING DIVISION PERMIT , CON, fCRAC.TOR IN ',UiMT*I,,N�-,
BUILDING ADDRESS: PERMITNO.
(W L• A meiiiepPERMIT I$
p - waiis
SANITARYN OLNO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�oz LICENSED CONTRACTOR'S DECLARATION
M1 hereby AM.that 1 am licensed under provisions of Capw19(commencing Job Description
with Section 7=).r Division Sof be Business madPIOICwions Coda.and my license 13In full tome and CrIbm.
� a License Claw Lot.A REVISED TRUSS/ROOF-=IN HOUSE USE ONLY
Z
p Dale Contractor
❑U<y ARCHITECT'S DECLARATION NO NEW PERMIT, ORIG. 401080045
�i 1 understand my pans shall W used As public moor&
3� Licensed Professional
OWNER-BUILDER DECLARATION
I 1 hereby drum that I am exempt from the Contramor's License law for IM
S:
00 following reason.(Section 70313,Business and proximo ns Code:Any city or county
$ which requires a permit to construct,altar,improve.demolish,An repair any structure
poor to is Issuance.also requires Mappllcant fanuch permit to File signed statement
g C that he Is licensed pursuant othe Provisions ofthe ContrwtM' Lice=Law(Chapter 9 Sq.Ft.Floor Area Valuation
gxC (commencing with Section 7000)or Division J of the Businessind Professions Cc*)An
3
that he is exempt therefrom and Bu:basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit wbjecu floe ApplicanLto A civil penalty Of APN Number S 6ttpa'ny Type
not more than Fiw hundred dollars($500).
O j,As owner of the property,ca my employes with mgu as baboon compensaden,
windy thework.and themmmla snot Intended M offered tbraam(Sec.7044,Business Required Inspections
And Prufeasiom Code:The Contromofs License law does not appy to an owner of q p
property who builds mimprons theroon,and whodoes Inch wmkhlmselfor through his 101 — FOUNDATION
ownemployes,providedthatuwhImprowmenutaenotinMnd MnRemdforule If.
however,the building or improvement is veld within one year ofcompletion,lbeawnen 102 — PIERS
builder will ban the human of proving that he did not build or Improve for purpose of
,.lea, 103 - UFER
O 1,as owner of the properly,am exclusively contracting with licensed cannot=to 104 - REBAR
construct a project(See.7044,Business and Professions Code:)The Contractor's LI- 105 — ANCHOR BOLTS
use,law dors not pply to an owner of property who builds or Improves Nencen,and,
who contracts for such projects with A eonuanoKU located purwanl to the Contactor', 106 - SEWER & WATER
License law.
O lwnscmplunder See ,B&PCrorthamnon 202 — UNDERFLOOR PLUMBING
D ere Dao 203 - UNDERFLOOR MECHANICAL
WORKER'S COMPENSATION DECLARATION 204 — UNDERFLOOR FRAME
Ihereby affirm under penalty ofperjurycan orthe following declarations: 205 — UNDERFLOOR INSULATION
❑Ihow And will maintain aCerllfisleolconsenttoself-a.ummrwork e.Compen. 301 - ROUGH PLUMBING
salon,As providod for by Section 3700 of the labor Code,for the performance of the
work for which this permit Is Issued. 302 - TUB & OR SHOWER
❑l haw and will mainwn weaker'.Compensation awsnc,As mqulmd by Section 303 — ROUGH MECHANICAL
3700 of the labor Code,for the performance of the wort for which this permit is Issued. 304 — ROUGH ELECTRICAL
My Worker's Compensation Insemnce carries and Policy number aro:
Carder..Policy No.: 305 - FRAME
CERTIFICATE OF EXEMPTION FROM WORKERS' 306 - HOLDOWNS
COMPENSATION INSURANCE
rlha.eeuon mead not W completed Btlme TIMOR to IMAM,hundred dmar.(SI00) 307 — INSULATION
mica..) 308 — SHEETROCK
1 certify that In the performance of the work for which this permit Is Issued,I mall not 309 EXTERIOR LATH
employ any moron many mannerw u to become subject o theworkeri Compensation 31O — INTERIOR LATH
Iaw,of Califomia.Dam
Applicant 311 - SCRATCH COAT
NOTICE TO APPLICANT:If.$flet making this CenlOcta of Exemption,you should
aenme wbjcm to the Workcem Compcossol provisions of the Lour Code.you must 313 - ROOF NAIL
JZ mrilcomply wwwehprovwonsor this permit"IAn, emWmwkcd' 501 - FINAL ELECTRICAL ENERGY
? CONSmisacONLtionleGAGENCY 502 - FINAL PLUMBING ENERGY
E
lar whichlty
ti�therohsued(S conn lending agency forma performance of 503 - FINAL MECHANICAL ENERGY
dm work for which Nis remit b issued(Sm.J097.Civ.CJ
]WE Lundeen NamAddr 504 - FINAL BUILDING ENERGY
Addrcu
z Lcnder'a
U O I madly that 1 how rad this application and mus that the bon Information a 505 - FINAL ELECTRICAL
D.F comm.I agree to comply with all city and county ordinances and sten,laws mating to 5 6 - GAS TES T
O U building convection,and hereby Mahodw re maentativct of this city to enter uram NC —
W ahovwmenOunW PMPanY for lnspeetian PurpusaL O FI44L PLUMB NG
(We)Agree to an.Indemnify and keep humleas Ute City of Cupertino against 0 8 — F I AL
..i ;,j Ilabilidu,judgmenu.eosu and expenses which may in any ray omw against said City
U I.^" APPLICANT UNDERuance of the STANDS ANDof WILLWILL COMPLY WITH ALL NON-POINT Issued by: 5 Dale
SOURCE REGULATIONS. —
Re-roofs 514 INAL PUBLIC WORKS
Signature of ApplluHAZARD or Dow
HAZARDOUS MATERIALS DISCLOSURE Type of Ro6t02 - ROOF PLYWOOD NAIL
Willy the Cupertino
futurebuildingode.Chapt.mmor handle avndound Stadol 603 — ROOF BATTENS
An deOned by the Cupertino Municipal Code.Chapter 9,13.$red the He$IN and Safety
Code.Section 25532($)7 All roofs SAY inspA'a@Form&An WR %&erial being installed.
• Man Oft
Will the applicant or forum Wilding acupam use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emu amdnus air cenuminsnR As defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑tic ONO
I have mW the haaardmms mawrisia requirements under Chapter 6.95 of the Califor-
nia Health a Safetycode.Sections 25505,35533 and 25534.1 understand that lithe Wilding
Jos not currently haw$tanani.that it Is my responsibility m notify IM Occupant M the
requirements which must W met poor udvuanw of a CcniOcate of Occupancy. Signature Of Applicant Date
Owner unullewl agent Dam All roof coverings to be Class nBn or better