03060001 CITY OF CUPERTINO
BUILDING DIVISION LGTaiOtR4N�, Ra. MATI'ONM "V
BUILDING ADDRESS: PERMITN"03060001
RACE. DR
ER'S NAME: PERMIT"W/A752/2003
AN REWARI
NE: SANITARY NO. CONTROL NO,
ARCHITECfyENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I� I�
u o p LICENSED CONTRACTOR'S DECLARATION
(esu I hereby afOw thm l am licensed under provisions of Chapter 9(commencing lob Description
with Section 70110)of Division 3 of the Bulinus std prolamin.Code.aM my license is /�
to ense0:andaffect. ADD 477 SQ. FT. P91111"'�ILEI®
j H z License Clm Lie.N
n DBLL' Coe DELL
ARCHITECTS DECLARATION
1 understand my plans shell he stud a public rccnrds JUL 0 2003
a
+g.Q Licensed Professional
OWNER-BUILDER DECLARATION 0,
I hereby of on rhes 1 am exempt fmm the Communes License Law for the BUILDING
0 0 following reason.(Section 703 t.5,Business and Portmium Code:Any city or county
g 0! which acquires a Permit to construct.slur.Improve,demolish,or repair my swcmm
_Z'y^ prior to insisuaue,also requires the applicant for such permit to File a signed suument
< that he is licensed pumommtiuprovisions ofNeCommunes UccomLaw(Chapter 9 Sq. Ft. Floor Area $70`6i[L0[Ion
E a (commencing with Section 7000)of Division 3 of the Business and Profusion&Cade)m
3- Nat he h exempt Ihemfrom and the buns for the alleged conniption.My violation of
Section 7031.5 by my applicant for a permit ubjmu the applicant to a civil penalty of 3 5*dPMVBor0 0 Occupancy Type
net anon Nen Ron hundred dollars($500).
0 I.uo mrofthepmNny,ormycmploycuwiNwguuftirwiowmpenution,
will do tie work and the structure is not intended or offered toualc(Sic,70M.Businessdins actions
and Professions Code:The Contractors License Law does mel apply In an owner of 10 2 - PIERS p
property who build.m improves thereon,end who deeuuch work himself er through his
eon employees.provided Nonsuch improvements tie not rounded maffued for sale.If• 103 - UFER
however.the Wilding or improvement is sold within one you of completion.Ne cortin
Wilder will have the burden of proving that he did not build or improve for purpose of 104 - REBAR
ale.). 105 - ANCHOR BOLTS
I,as owner of the propeng am exclusively contracting with licensed contractors to 106 - SEWER & WATER
o wet Ne project(Sec.7044,Business and Prifeaiom Crede:)The Contractor's Lb
came law dors not apply town Owner of propany who bund,or improves marcon,rod. 202 - UNDERFLOOR PLUMBING
who contracts for uch projects with a contractor(s)licensed pursuant wthe Contractors
LicenseIsw. 203 - UNDERFLOOR MECHANICAL
0 I am exempt under Su. .B&PC for this reason 204 - UNDERFLOOR FRAME
6DZ tot 205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARA 301 - ROUGH PLUMBING
I hemby aiilrm under penalty of Permy ensnnite fol ewingdeelaenons: 302 - TUB & OR SHOWER
I hew and will maintain•certificate or Cement la ul6imure fm worker's Compen-
and en..............................uprovided for by Section 37M of the Labor Code,far the performance of the 303 - ROUGH MECHANICAL
work err which this Permit is issued. 304 - ROUGH ELECTRICAL
❑1 have and will maintain Workers Compensation Insurance,as required by Section 305 - FRAME
37W of tM m
Labor Code.for the performance of the work for which this permit Is issued.
My Workers Compensation Insurance carrier and Policy number mc: 306 - HOLDOWN.S'
carrier. Policy No.; 307 - INSULATION
CERTIFICATE OMPENSATI(ON INSURANCEPTION FROM ORKERS' 308 - SHEETROCK
(Thissecdoo need not W completed iflW permit is rormehundmddollan($10o) 309 - EXTERIOR LATH
irla...) 310 - INTERIOR LATH
I cenify tial in c rfermaac of the work for which this Permit is issued.I shdl nm 311 - SCRATCH COAT
employ soyif any munCr asp W ewbject mtM Worked Compensation -
Lawsofonto ta ALS+-� 313 ROOF NAIL
Applicant -�-
NOT�C�TOAPoulk.W.Am's ormmakmNnCemnnuo Labor .di%y Mould 501 - FINAL ELECTRICAL ENERGY
bccmwi coutm it WodproCanpewhonpmvitmaiofthclroMrCodod. must 502 - FINAL PLUMBING ENERGY
,J,� leMwi comply with soch provisions or Nis Parrott mail Wdeemed mvmked.
?
CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
Thereby off.that ft.1.ti, nsusailmn leading agency for ft perfowmen of 504 - FINAL BUILDING ENERGY
a> the work for which this permit tsssad(Sa.3097,Civ.C.)
lenders Name 505 - FINAL ELECTRICAL
4i1 Q
Z LaminesAddrca 506 - GAS TEST
U 0 1 cavity dist I have mud this application and sou this the above information is 5 0 7 - FINAL PLUMBING
it, ^ correct.I ague to comply with all city and county ordinances and suns laws toting to
0 rU^ buildingcouwction,andherebyuNorixrepresentativesofhiscityinan'W%pionftFINAL MECHANICAL
Ii7 above-mcmiuned property for impecoon purposes 09 FIN
lL (We)agree to caw,indemnify and kap harmless she City of Cupertino against
y
liabilities,judgments,core and expenses which may in any way secrue against said City IWNG
C.1 in consequence Ortho crating of this permit.
APPLICANT�f U�31N"D�ERSTANDSAy�ND WILL COMPLY WITHALL NON-POINT Issued by:5 WORKS Date
U0.CER 1 71Q O.WNT1n/� NUv�*AN. / 6IbZl� .
Re-roofs
Signuurc efApplicuVConRDOU Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the applicant or furore bullJing eccupam uorc or handle heuardou&material
u defined by Ne Cupertino Municipal Code.Chapter 9.13.and the Health and Safety
a.Section
35533(a)7 ��Q`Ne All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding aaupent esu equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it Mardnu air contaminants a defined by rhe Bay Arta Air Quality Mansgcmcnl all new materials for inspection.
DiwinT
❑Yes �u
Thaw mad the haardnns meuriels requircmcnu under Chepur fi.95 of the Califon s
ria HcolN&Safety Cmlc,Sm6om35505,33533wd35534.1un&m=dthuirthe Wilding
docs not cumendy love a mnsm Not it is my msponsibility to notify the acuput of the
reyyimmen _ ich mud^uec n �amnaenceninaaeerlxa\.10 - Signature of Applicant Date
r m,a V_PAd sort to All roof coverings to be Class"B" or better L