03060181 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INF.ORMATIOW-,
BUILDING ADDRESS: KSYC CONST PERMIT N003060181
OWNER'S NAME: 24704 MAGNOLIA ST PERMIT ISSUE DATE
E: SANITARY NO. CONTROL NO.
(510) 726-3182'
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
0 0 0 0
air, LICENSED CONTRACTOR'S DECLARATION
I hereby ofErm that I mm licensed under pmv rte of chapter 9(Commenting Job Description
n� wiJy5 lion 1a103sf Divieum 3 of NC Business an Csiom Code.and my license is
in ful'oreemd effect. ADD 64 SQ. FT.
Lie xClan Le.a
i FFq p'�
Data Cents
Iuodcnu lam shallh usedDis public records AUG 7 2003
SyU
s G� Licensed Pmfcasm
A 3 OWNER BUILDER DECLARATION
Contr ON BUILDING
<� 1 hereby affirm,on 11. exempt from the fession.C's License Law for the
COO follwhich re mason.Permit
t 1 o str Business and Profession.ns Code:Any city or county
Zis which reyuseeae.also recnresteLalters improve,h Perlia or repair anystructure
nnn
y pnonniuiensedprsuant 10 the theapplicant for sucContrator'toicele ssigned aw(Calcmcm
F-¢s�s< that he it licensed pursuant 7 the of Division
of their Contractor's nd Prefllw(C oda)9 Sq. F[. Floor Area Valuation
yF0
(commencingheisxempt Senion1000)of Divisionr sftheegei cuondon.Any
Coda)or
Nn he is exempt Omrerrom and the buss for dm alleged eumpuon.Any violation of 3162 8004 . 00
Section 7031,5 by any appliCanlfor 4Permit Subjects theappficanmaCivil penalty of APN Number Occupancy Type
not mom than five hundred dollars(SS00).
❑I.as owner of the property,or my employees with wages as their 3019 compenullon,
will do the work,and the structure is not intended or offamd fontic(Sec.104q Business iUi - d Inspections
and Professions Cade:The Contractor's License Law does not apply to an owner of 10 2 - PIERS p
property who buildsur improves Wemon,and whodmthrough ssuch work himseror rough his
own employees,provided that such Improvements are not Intended or offered forsale.It. 103 - UFER
howeveq Ne building or improvement 13 sold within one year 0f completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of 104 REBAR
ml`')' 105 ANCHOR BOLTS
❑L�t the pmfthe propan,, clusively contracting Codc:)ensedcontncmum 106 - SEWER & WATER
construct the project apply
to
ooan Business and ny who
Code)Them Ramada. std
came Law does r such plr man with
aofpmpeny whosedpds orant in
Ramada.and 202 — UNDERFLOOR PLUMBING
who contracts for such projects with a contnemr(q licensed pursuant m Re Comm�oh
Licenml.w 203 - UNDERFLOOR MECHANICAL
❑I am exempt under Sec .B A P C for this recon
204 - UNDERFLOOR FRAME
net Date 205 - UNDERFLOOR. INSULATION
WORKER'S COMPENSATION DECLARATION
I'.'y a".
ander penauy of perjury one of the mnowmg declaradons: 301 - ROUGH PLUMBING
( IMce and will mainuinaCcocle of Conxnuo"'B'mum forWorkehCompen. 302 - TUB & OR SHOWER
Cation,u provided for by genian 3]00 of the Lobar Code,fm the peRormenc9 of the 303 - ROUGH MECHANICAL
.,it for which this permit is issued.
❑1 have and will maintain Worker's Compematlon Insurann,as required by Section 3 04 - ROUGH ELECTRICAL
nal of the Labor Cods,fordmpertormancoorthe work for which this permitisissued, 305 - FRAME
hl"Ady_W kcra Cn nsauon lnsunnce nrr'cr end Poli nu Mrare: 306 — HOLDOWNS
C! /ls. Policy No.:
C!xnFICATEOFEXEMfT1ONFRO WOR — 307 - INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
ocean) P
Cnot action need not he completed if theermit is(inone hundred dollars1$101) 309 - EXTERIOR LATH
310 - INTERIOR LATH
e certify Nm in the in any
of the work bforecome
which this permit is issvod,l cull not
Lawsof any person any mannerxumhecomc wbjen to the workers Compewtion 311 — SCRATCH COAT
Laws Of California.Data
Applicant313 - ROOF NAIL
NOTICE TO APPLICANT.If.after making this Ccnificam of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become subject to the Worker's Compensation provisions of the Labor Code,you must
0z forthwith comply with such provisions or this Permit shad hedeemed mvokcd. 502 FINAL PLUMBING ENERGY
z O CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
[—t 4 Ihereby aMrmchat ft.is.comWctinniendingagentyCarideo performanc9of 504 - FINAL BUILDING ENERGY
7 the.,it for which this Permit is issued(Sec.3091.ON.C.)
W p
Lender's Name 505 - FINAL ELECTRICAL
= z <nder'eAadrem 506 - GAS TEST
U O I"nify that I have mad this application and rex But the above informauun is 507 - FINAL PLUMBING
I, F correct.1 agree I.comply w W all city and county ordinances and euro laws relating m
pU buildingcamwction,and herebysuthodmmprexnutivee0fthis citytoenterupnnthe WF
JEON CAL
W aNnvcmcmicand p.,rty for inspection purpoxv
(We)agree m use,indemnify and keep humlem the City of Cupertino ageinsl O 9
fn IiabiliOu,Judgmcote.cosLLand cxpcnu3whichmayincry way ucrucagainstmidCity 5 G
U7 in conxyucne9 of the granting of this permit.
r7• APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:5 WORKS Date
-07
SOURCE REG ATIONS.
4 Re-roofs
Signe o piicant/Contrumr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof ?sem
Will the applicant or future building occupam store m handl.hmudous material
m za by the Cupeninn Municipal Cub.Chapter 9.12...d the Health and Safety
We. Ely.2553:(a)? rrrJJJJJJ All roofs shall be inspected prior to any roofing material being installed.
❑YesNu
Will the applicant or future building occupant use equipment or dcviee3 which Ifaroof is installed without first obtaining an inspection,Iagree to remove
it hmardous air conuminanu ss dcfncd by Nc Bay Arca Air Quality Management all new materials for inspection.
cadet?
❑Yes <No
Ih1vc mad the hmardtms materials requirements under Chapter 6.95 of the Califnry
nia Hculth A Safety Codc,Sccuons 8505.25533 and 35534.1 undersand thuifthc building
does nut cunemly hovea tenant.ton b o my reapunsibility to nsdf the tccupmt of Ne
reyuiremcros ichmustbemopnorutiuumcenfaCenfcaaSignature of Applicant Date
Owner osivcd apcm L Dam All roof coverings to be Class"B"or better