03080180 CITY OF CUPER•fINO
BUILDING DIVISION PERMIT kCONTRAC—TOR,INIORMATION E'
BUILDING ADDRESS: CHARVEZ CONSTRUCTION PERMIT"°03080180
32:7 TONITA WY
:R'S NAME: PERMIT ISSUB DATE
360 W 8TH ST
PHONE: (408) 893-7693 SANITARY NO. CONTROL NO.
ARCHITECTICNGINEER: BUILDING PERMIT INFO
BLD ELECr PLUMB MECH
jO0 LICENSED CONTRACTOR'S DECLARATION O O
� F❑ 1 hereby affirm that I am limesed under provisions or Chapter 9(commencing Job Description
<W with Sermon Irsa)of Division 3 ofthe Business and Prufcazba Code.and my license is
i'q: �i�,�l.Clmmand erfec` Lic.g REVISION--IN HOUSE USE ONLY
Dare Contractor NO NEW PERMIT ISSUED/ORIG. 403040092/03070176
ARCHITECTS DECLARATION
f w U I understand my plans shall be used as public reenNs
pt, Licensed Professional
in S OWNER-BUILDER DECLARATION
�f 1 hereby affirm that I am exempt(rum the Contractor's License Law for the
OO following reason.(Section 7031.5,Business and Professions Code:Any city or county `
<$ which requires a peril In construct,alter,improve,demolish,or repair any structure V
-�Zi> pdo to its iuuunce,also requites the applicant forsuch permit to file a signed statement Valualifx�107
F� that he is lice used pursuant the provisions of the Contractor's Lim Law Sq. Ft. Floor Area
(commencing with Section 7000)of Division 3 or Business and Professions Codc)or
Not he Is coni tbemRom and the basis for the alleged exemption.Any violation of
Section 7031.5 by by applicant for a perp subjects Ne applicant to a civil pentlty of 3$1�AT4aUI�er00. . Occupancy Type
nm mom Nan rive hundred dollars($500). '- - - - —- P Y ---
❑Las owner of the property,or my employee with wagaathcir sole compenmion,
will do the work.and the swnute is not intended or offered for ate(Sec.7044,Business -
and PwR„mn,Code:The Conugror,License Law me not apply to an owner of - Required Inspections -
property who builds orimproves thereon,and who does such work himmlfor through his 101 - FOUNDATION
Own employee,provided that such improvements art not intended or offered bonds.If, 102 — PIERS
however,the building or improvement is sold within one year of completion,Ne owner-
budder will have me burden of proving that he dm not wild or Improve for purpose of 103 - UFER
m1e.). 104 - REBAR
t1,as Owner of the property,am exclusively contracting with licensed contractors to
nsracl the project(Bee,7044,Business and Professions Code:)The Contractor's Li. 105 — ANCHOR BOLTS.
come law does not Apply to an owner of property who builds or improves thereon,and, 106 - SEWER & WATER
who contracts for such projects with a contractor(s)licensed pursuant o he Contracor's
cern"Law. 202 - UNDERFLOOR PLUMBING
#11m ex,, �teu�nd�e/,`5SS^�eeee��.``,t��4{{��,,QQ'' ,B h P C for Nis mamm 203 - UNDERFLOOR MECHANICAL
a WxORKER'SCOMPENSATIOND ATTION& l03 204 - UNDERFLOOR FRAME
I hereby alrmn under pemlly of perjury oroo emlowing emanations: 205 UNDERFLOOR INSULATION
❑thaw and will maintain aCertiBeateofComemtoselr.laumfor Wettrracomper- 301 - ROUGH PLUMBING
satian,a provided for by Section 3]00 of the Labor Code,for the perforans of the 302 - TUB & OR SHOWER
Permit work for which his is issued.
❑1 have and will mountain Workers Compensatipn Insurance,as mquimd by Section 3 03 - ROUGH MECHANICAL
370D of the labor Corm,for the performance of the work for which this peril is issued. 304 — ROUGH ELECTRICAL
My Worker's Compensation Insurance carrier and Policy number am: 3 05 - FRAME '
Cubic,: Policy
OFEXEMPTION YFROM WORKERS' 306 — HOLDOWNS
COMPENSATION INSURANCE 307 - INSULATION
,it le,s.)
rrhis section need Or,keomplawd if farm it for one hundred donar,(s100) 308 - SHEETROCK
309 - EXTERIOR LATH
employ certify Nater the in an mann of Ns work for which thio permit is issued.I sha11 not
Law .anypersonmany manncrwazmbecomesubjmuotbe Worked'Compeaa0on 310 - INTERIOR LATH
Lawsce California.Dale
Applicant 311 - SCRATCH COAT
NOTICE TO APPLICANT.If.after making this Certificate or Exemption,you imald 313 - ROOF NAIL
become subject to the Worker's Com Fensation provisions or tae labor Code,you must
]o forthwith comply with such provisions orthis Permit sha0bedeemed invoked, 501 - FINAL ELECTRICAL ENERGY
z nCONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
I hereby affirmNat there is a construction lending agency for the performance Of 503 - FINAL MECHANICAL ENERGY
Lend.,'s NNorm,x theorWhich lhis r'nisiaucd(Sce309],Civ.C.) 504 - FINAL BUILDING ENERGY
37 A nder'a
D z Lcneer's Address - —
C) 1 early that 1 have read this application and sum that rise above information is 5 0 5 FINAL ELECTRICAL
y Confect.I agree to comply with all city and county ordinances and stale laws relating to 5 06 - GAS TEST
�U above
-mentioned
hereby authonprposexnutiwsof this city tocorerup�n Nc %08F
IN PLUMBfIN
G
1 ahovenmentstrut property for inspection purposes.
representatives
^ (We)agree to eve,indemnify and trop humlev the City o!Cupcnino aleiat I L
liabilities.judgments.costs and expenses which may in any way game against mid City j z incense cc ofill, tingofNis peril.^ APP ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: GDate
5 RCE RE ULATIONS.
UPA NZ Q' ��03 Re-roofs 4 NAL PUBLIC WORKS
Signature of ApplimmiComracmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle haelmous material
enned by the Cupertino Municipal Code,Chapter 9.12,and the health and Safety
.,schen 255324n -
❑Ye, `�j"o All roofs shall be inspected prior to any roofing material being 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
emh hazardous air conmminants in defined by the Bay Area Air Quality Management
obldct7 all new materials for inspection.
❑Yes PNo
I have read be hamtenus materials requirements under Chapter 6.95 or the Califor,
M.If "Safety Code.Sxfim 5505,35533and25534.Iundcs,Iandthuif N.e wilding
it not ti newly haw a tenant,Nal it u my responsibility w notify do Occupant of be
aimments soh It Stormer PtlOttuiauansofa CealMatof Ocmancy. Signature of Applicant Date
WimpulA!_ Q x� 3
Owner or iuthoriwdugenl Dore All roof coverings to be Class"B"or better