02070047CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTRACTOR
INFORMATION
BulT5l TRr9VICKSBURG DR
PERMITNO2070047
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W IBMINTAN HOWARD
APPLICATLjR7S U)gry2O 02
Al - SONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC"
0 0 0 0
LICENSE.. CONTRACTOR'S DECLARATION
1 hereby affirm that I am Il provi,iI of Chapter 9 (mmmcnse
ADD
202 SQ RN6999,
with Sar 7 fia Bounder
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3 of me Business enJ Pnsfcainns C,Wc, coil my license is
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in fall force ad {fico
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DECLARATION ARCHITECTS DF.CfARATION
I understand my plans shallM used as public records
JUL 17 L9003
LittnaJ I'mfemional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt imam the Contractors License Law for the
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UMe:
following reason. (Section ]1131.5, Business and Professions COLIC: County
Any city cou
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which requires a permit m construct, alter. improve, demolish. or repair any mme ae
poor to its issuance, also requires the applicant for such permit In file a signed slatemem
that he is licensed pursuant to the provisions of the Connector's license Law (Chapter 9
-*9Et8iDdo7A@@
Valuation
(commencing with Section 7100) of Division 3 of the Business and Professions CodA) or
that he is Attempt theefmnm and me basis for She alleged exemption. Any violation of
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Occupancy Type
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Section 7031.5 by any applicant for a permit subjects the applicant to a civil piounlyof
not tame man rim hundred dollars ($500).
102
— PIERS
❑ I, AS owner of the propeny, or my employees with wages as their Sale compensation,
will do me work, and the swcmm is not intended or offered for ale (Sec. 7044, Business
and Professions Cade: The Contractor's Licence law does not apply to an
Required Inspections
Owner of
104
- REBAR
property who build& Or improves Ihemon, and who does such work himself or through his
Own employees, ponied that such improvements are not intended or offered for ale. If,
105
— ANCHOR BOLTS
however, me building or improvement is sold within one year of completion, the Owner -
106
- SEWER & WATER
builder will have the burden of proving that he did not Wild or improve for purpose of
ale.?
202
- UNDERFLOOR PLUMBING
pAmowner ofthe property, Fan ettclasivelycontracting wimlicensed convactmein
203
- UNDERFLOOR MECHANICAL
construct the pmjee (See. 7044, Business and Professions Carl The Comment's Li.
cense law does not apply to an owner of property who builds a'improves Often., and
'
204
- UNDERFLOOR FRAME
icenaµna for arch projects with ronmacmr(sHpursuant mthe Contractor'sa.
Lse L
205
— UNDERFLOOR INSULATION
❑ lam exempj under Sec. ,B&PC pulltan rasa
/.
301
- ROUGH PLUMBING
OIL()
302
- TUB & OR SHOWER
/ WORKERS COMPENSATION DEC LAR N
VA
303
- ROUGH MECHANICAL
I hereby affirm under penalty of perjury one of he following declarations:
3O4
— ROUGH ELECTRICAL
Ihave and will naCion 37 k of
LaluOCode,for for Worker's Compere
305
FRAME
&tion, a provided for by Section ]7W of the labor Chile, for me performance of the
for der
—
work for which this proton is issued,
306
- HOLDOWNS
❑ 1 have and will maintain Worker's Compemation Insurance, m required by Section
3 07
- INSULATION
3701 of the Labor Code, forme performance of the work for which this permit is issued,
My Worker's Compensation Insurance artier and Policy number are:
308
— ,SHEETROCK
Cartier: policy No.:
309
- EXTERIOR LATH
CIiRTIPICATES- OF EXEMPTION FROM COMPENSATION INSURANCE
310
310
- INTERIOR LATH
(This.[... a need of he completed if the permit is l i•nme hundred dollars (Man
311
- SCRATCH COAT
moss.)
313
- ROOF NAIL
I eenify mat m to sAgQrmmMo of the work for which dais permit is issued, I shall not
employany perttm'any manner Wits to hecomeaabjccllth6 Workerarrn egsation
501
- FINAL ELECTRICAL ENERGY
Calif9mir Datc • // Ilsstt //VV II i
Lopw�yy,
502
- FINAL PLUMBING ENERGY
rrOO/F
503
- FINAL MECHANICAL ENERGY
,,(p—i�fs
NOMETOAYPI ANTCeMrmakingorisCenifcatcnfEumptian.youshould
Meme subject tat aWorker's Compensation provi,iam of the labor CnJeyou must
forthwith comply with such provisions or this permit shall be deemed revoked.
504
- FINAL BUILDING ENERGY
505
- FINAL ELECTRICAL
CONSTRUCTION LENDING AGENCY
I hereby alTrm that mere is a construction lending agency for the performance of
506
- GAS TEST
the work for which this permit is issucd(Sec. 301H, Co, C.)
507
- FINAL PLUMBING
Lender's Namc
506
- FINAL MECHANICAL
Linder's Address
I certify mat 1 have read this application and state that the above information is
509
- FINAL GRADE
correct. ( agree to comply with all city and county urdinantts and stare laws relating m
building constitution, and hereby authnfim representatives of this city m enter upon the
5
FINAL PLANNING
shove -mentioned property for inspection pmpmcs.
(We) agree IO ave, mccomi fy and keep harmless the City of Cupertino against
14
— FIN I C W RK S
liabilities, judgments, casts and expenses which may in any way came against aid City
in consequence of the granting of this permit
APPLICANT UNDERSTANDS FIND WILL COMPLY WI'rH ALL NOPOINT
Issued by:
Date
$OUR E GULATI N ),IJ
a -roofs
Type of Roof
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. goal r n PPhcaHAZARDOUS MATERIALS DISCLOSURE Dale
Will the applicant or future building oecePant scare or handle hanolous materiel
as defined by the Cupertino Municipal Code. Chapter 9.12, and the IIcahn and Safety
� ode, ours 25532(A1 10/1
All roofs shall be
inspected prior to any roofing material being installed.
.of
If a roof is installed
without first obtaining an inspection, I agree to remove
Will the applicant of forum' ng arupant use equipment nrdeviccs which
emit ho.ninas air ,crmmiran a�d'rmed by the Bay Area Air Quality Management
all new materials
for inspection.
Dissnct9
❑Yes No
[g✓
1 have read me houndous materials tequircmems under. Chapmr6o5 of me Califon
fi
nia Health&Safety Cote,S=om25505,25533wd25534. lundeMawp
does not currently have a mnan4 mat it is my responsibility to a
requimmc IL th bemclp or to issuance of a CertificateSignature
Of Applicant Date
All roof coverings to be Class "B" or better
Carrier
m oath utmal agent