03020068 (2) CITY OF CUPERTINO * ' � " �° �� < •' ' . we 's�'
BUILDING DIVISION PERMIT CONTRACTOR INF,ORMATIQN^
BUILDINGADDRFSS: MATZ CONSTRUCTION PERMIT NO. -
R'S 10574 ORANGETREE LN APPLICATI A
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PHONE: (4.08) 257-6376 ONSANITARY NO. CTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Lao fiONnRACrORSDECON
I Mmhy affirm that Iamlicensed under provisions nfChapkr Y(commencing JobDescri
Description
wishScnon] m FINALE® o
In to
«e N KITCHEN REMODEL/WINDOW UPGRADE 0
j Lice C v
OCT 2 2003
ARCHITECTS DEQ� ARATION
y @� 1 undcrstend my plena,hell M uecJY3pumic records
a LicensedProfcasimal BUILDING
OWNER-BUILDER DECLARATION pa�y
<Y 1 hemhy affirm on 11. exempt from Ne Contractors License Lew Ro the
o O which ire mason.(Section]1131.5.Business end improve.
de o demolish.
Code:Any city os county
X$ which requires n Permit re uir construct.eL Jur.improve,do ermit t or repair any structure
prior m its issuance,also requires the applicant for such permits.tilt a signed aukmcm
AZO
that he is licensed pumrant to the provisions of the contractors license Law(Chapter 9 Sq. Ft, Floor Area Y
$256b161ion
$ (commencing with Section 7000d of Division 3 of the Business and Foresaw.Croke).,
Vu
A. Nat M is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by eery applicant fore permit subjects Ne epplicanno a civil pertly of 3}1�,� ggl�er00 Occupancy Type
not more Nan five hundred dollars(SSW),
❑1,As owner of the property,or my employee,with wages a their sole compensation, '
will do the work,and theathroMe isnoNntended or offered for sale IS".7044,Business 101 — FOUND
and Profeashms Code:The ContractoM1 License Law does not apply to an owner of Qid Inspections
property who builds or improves Hereon,and whodoesawlt work himselfor through his 102 - PIERS .
own employees,provided thauuch improvements Are not intended aro@red for tele.If, lO3 — UFER
however,the building or improvement is sold within one year of completion,the owner
builder will have the burden of proving that M did not Wild or improve for purpose of 104 - REBAR
tele.).
❑I,as owner of the property,em exclusively contracting with licensed convectors to 105 — ANCHOR BOLTS
construct the project(Sao 70W,Business and Professions Cade:)The Convsmori u• 106 — SEWER & WATER
sense law does not apply to an owner of property who Wilda or improves thereon.and, 2O2 — UNDERFLOOR PLUMBING
whocom for such projects with a contractor(s)licensed pursuant to the Cantranor'a
L1eC 203 - UNDERFLOOR MECHANICAL
m'1 em exemp under Sec. .B&P C for this Much -
204 - UNDERFLOOR- FRAME
WORKER'SCMPRNSATIONDEC OON 205 UNDERFLOOR INSULATION
I hemhy elBrm under Penalty of perjury...of the Following decluanons: 301 - ROUGH PLUMBING
❑IhnveanJ will mainWne CeniBcek ofCnnsemloself-irtsumfor Worker'.Compen. 302 — TUB & OR SHOWER
scion,a provided for by Section 37W of the Labor Code,for the Performance of the 303 - ROUGH MECHANICAL
..,it for which Nis Permit is issued.
❑1 hats and will maintain Workers Compensation Insurance.As requited by Section 304 - ROUGH ELECTRICAL
37M of the labor Code,for the performance of the work for which this Permit is Issued. - 305 — FRAME
My Worker's Compensation Insurance carrier and Policy number art; - 306 — HOEDOWNS
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 — SHEETROCK
lir lcssJ(This section need..[beeompleted ifthe permit is Damns hundred doll0(SIRB) 309 — EXTERIOR LATH
'— Iccnit Nei�in the pe prmance of thc'work for which this Permit is issued.)shall not - 310 — INTERIOR'-LATH
employ any pe ni nymannersna m become subjauothe Wmkcrs'Compe.sail n 311 - SCRATCH COAT
Lawsof CJifomi u
APith t 1 313 - ROOF NAIL
N TO APPLICANT:If,afurmaking this OcnificaleofExemption,you shoulJ , SOI — FINAL ELECTRICAL ENERGY
Mmdle'aubjm to the Worker's Compensation provisions of the Labor Code,you..at
oz forthwith comply with such provtionsorthis Permit shaBbedeemed mvokcd. 502 FINAL PLUMBING ENERGY
z CONSTRUCTION LENDING AGENCY 503 FINAL MECHANICAL ENERGY
[r rNi I botchy affirm that there ls.emo=tlan lending agency for the performance of
C> the work for which thiape.it isissu.d(Sec.YN7,Co.C.) 504 FINAL BUILDING ENERGY.
W q Lender',Neme 505 - FINAL ELECTRICAL
6r Lendcri Address
U0 I certify that I have read this application and sou that the aMve information Is 506 - GAS TEST
caed l ag me f.nop1r iutrancountrominans and auk laws ng to
507 - FINAL PLUMBING
OU building consuuction,and hereby othome rcpmsemetives of this city to enter upon the
aMve-mentioned property for inspection purposes. FI&&NG CAL
r0. (we)agree to save,indemnify and kap harmlen ties City of Cupertino against - 0 9 F I
(n hablliBes,judgmcnta,costsand expenses which may in ayweyaccrue agalmstssid City 5
C.1 in APPLICANTeof the UNDERSTANDS Aof tND WILL COMPLY WITH ALL NON POINT Issued by:5 WORKS Dat
S ERCGU TI NS.
Z5? fqA
'r 12' 47:3 Re-roofs
nstumMApplman/Contracto, - DateHAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant.,future building occupant storcmhan chevardua mekrial
defined by the Cupertino Municipal Code,ChaPur 9.12.And the Health and Safety
Sictim,oYm,255324 60.
)? All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupant on equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit ha,amoa air contaminant rado d by the Bay Arca Air Qumity Management all new materials for inspection.
District?
QYea
I have mad the havam.ua materials requirement under Chapter L.95 cribs Califon
lila Hcutth&Safely Crate.Secdoahatit.25533 and 25534.1 undersand thkifthcbuilding
run not cu cntly have a h
that 0 is 35 m 2553.1 to understand
t n ifthe b of the / rb
reyu ,which mus et pri Tri cm Ccnific� a ,mer. Signature of Applicant Date
r or wthorizeJ agent Dak All roof coverings to be Class "B"or better