02070209 CITY OF CUPER'1'INO WO?
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BUILDING DIVISION PERMIT CONTRACTOR NNK IRT-ION::_,
nlu R4oDOzESVAI AVE R & Z DEVELOPMENT PERMIT NO 2070209
R'S&AMg DEVELOPMENT 21771 STEVENS CRK BL #100 A"'Ll"A"19"I"Y"TITY2002
C
)NE: (408) 252-1101 SANITARY NO. CONTROL NO.
ARCIIIPCr/F.NGINEF.R: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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Op LICENSED CONTRACTOR'S DECLARATION
F 1 hereby affirm that 1 am IiecnxJ under provisions of Cha ler Y(,nom encin e
wi;hS'.tiortMailofDivision3uftheBusinessandProfessinnsGNe,andmylicenxrc NEW SINGLE FAN)'P �I�ER ING
� � ma, lnxead,eBecl. LIVING SPACE 3750 SQ . FT.
ccnx Clnss Lie.#
04g�n LiDale Cnnlmelnr GARAGE 670 SQ. FT.
ACI If FECTS�oi IundcrsunJ my plansshall Mused as ublic rccmds FINALE®
U
Licensed professional JUL
F�•.S OWNER-BUILDER DECLARATION 2 2 2003
as �y 1 hereby affirm that I am exempt from the Comramors License Law for the
w00 following reason.(Section 71171.5,Business and Professions Cade:Any city or county
$ which requires a permit to construct.alcor,improve,demolish,or repair any structure
I_ prior(it its issuance.also requires the applicant for such permit o file asigned statement
Oqq< that he is licensed punuanuothe provisions ofthe ContactorsLicense Law Chamr9 Sq. Ft. Floor Area tion
f (commencing wt.(Section 71(X1)of Division Sof the Basin,,unit Profexslone CnJe)nr
$ that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section]1131.5 by any applicant for a permit subjects the applicant to a civil penalty of -3 bAWN"bep
Out are Nan Eve hundred delta,,115f02 Occupancy Type
1,osownerk.and
property,ur intended
wildwages r Nei(xlc cnmpcnsineses
will d.ffewoh.ands he Confalmintended nrafwd forale(pec.]fl an,Business
and professions Code:The vesthecmri Lt..Odbo few does not apply lf an owner of 102 - PIERS egmred Inspections
property who buildsored tha sebcrcon,°nitwho dorosmh work bimxlforNm.[a his
howtwoempinyecsilding or imrsuch imps saild nuaaOut earOcJonslfemd for Camey-. 103 — UFER
however.Ncavete mimpmvement ingthalthe did
nad One bidder completion.the
p.of 104 — REBAR
hu'Jcr will have the burden of proving that he JiJ not build nr imrmvc for purpose of
° C.). 105 - ANCHOR BOLTS
rmlpe
hepmny.am.xm .n ivelyetin&with licensedcontmm &maln 106 - SEWER WATER
m th
nxrme project(Sea 7144,Busi ss and Pru cions CO II The Convector's Li
CnS wdocanotap oannwne efproperty b.Wilds or Improve;thereon.and, 202 - UNDERFLOOR PLUMBING
mtrs p 'c with amoK c.nuIicenxsun
dpurennNeCOmracmr',
Le
acufn
203 - UNDERFLOOR MECHANICAL
I e end.Se Big 6rrmrs 204 - UNDERFLOOR FRAME
205 - UNDERFLOOR INSULATION
Y E IN CLAJMION 301 - ROUGH PLUMBING
III eb f m n rpe. yof perjury rte of the following decimations: 302, — TUB & OR SHOWER
have ad willmaintai CerrficaleofConsent tosev-inmafnrwnrkeracumpen- 303 — ROUGH MECHANICAL
tint,ms Inside far by Section 3]1X1 of the labor Code,li+r the pertn'mance of the
work For which Nia permit is issued. 304 - ROUGH ELECTRICAL
❑1 have moil will maintain Worker's Compensation Insurance,as required by Section 3 05 - FRAME
3710 of Ne Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance Cartier said Policy tumbersrc: 306 — HOLDOWNS
c°mer: Policy No.: 307 - INSULATION
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 308 - SHEETROCK
(This section need not M completed i rmnis form undyed4m(SUM) 309 - EXTERIOR LATH
l`t,.) 310 - INTERIOR LATH
I.endyth meperbrman t liar« 311 - SCRATCH COAT
'I a ry ymanr r m u a c to
Lawn��p m'm ' r am 313 - ROOF NAIL
Ofls[J t r .sec ptio .should 501 - FINAL ELECTRICAL ENERGY
Mao t. .¢er9c. peori pmvisf.naof hederadr C.yo.m.n 502 - FINAL PLUMBING ENERGY
,z, forthwith ly iih such provisis rt I s rmit°hail M JcemeJ m.kcJ.
z O 503 - FINAL MECHANICAL ENERGY
CONSTRUCTION DING AGENCY
F '4 1hereby aMo.cl dmco,I..conavuclinnleodingagencyI beperformanccof 504 - FINAL BUILDING ENERGY
a > Ihcworkku tochdid perylicsissued(SC,NN7.Civ,C.) 505 - FINAL ELECTRICAL
WW 0 -cats Name —
z LenJcr'1Addxa 506 GAS TEST
U O I certify that 1 have rite.this application and sum ces the son.law,
information,rlg is 507 - FINAL PLUMBING
W (•-' anrtcct.lagree toComply wiNallcity and County oNinanccsandsmlclawsrelatingto 5 FINAL MECHANICAL
building conswction,and hereby aurhorire rep'cxnutivea of this city m enter upon the
aMwc mentioned properly for ins '4-hihfp�w
O9 FIN
We)agree to: ve,in nass Ne ny of Cupertino against E
h liald s,judgmems,cusrs ilea any/w attaeagainstaidCity 55 N G y� /
U r PPI Of UGRra AND PLy' ITII AL1. NP NT Issued by51 WORKS Date50 E /
Re-roofs603 - OF BATTENS
S n r i`aH Z USMATfiRIALSDISCLOSURE D, Type ofl�OG} - ROOF IN-PROGRESS
ill Nc applies r fu isbuilding ttcupam stmcor handle haardousmmOm!
as JCfi cd by the Cupcni n A nicipal Gac,Chapter 9.12,and the Health and Safety
tae mann 25512(a)7 All roofs shall be inspected prior to an roofing material being Installed.
❑Yea P P Y g g
Will the appiicam or fu rc building cecupam sax equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
t ha'aNnus air mnumiamdas defined by the Bay Area Air Quality Management all new materials for inspection.
nricR
C]Y. NO
vcrcad Nc hal ons u'ahm,ci cosmad Chapter6,95ofNeCalifnr-
a alt yQae, coir i553 .25534. ndeamnd Nmif hudding r
res not y h . fen But t's'm sprmslbil' - a the r pont r Nc
he 1 u M of - am ignature of Applicant Date
ow 'ora hmi'dir'y A Of, All roof coverings to be Class "B" or better