03060118 CILDTY OF CUPERTINO x� 7 :mgq,� =K-
BUILDING DIVISION PERMIT XQNTRACTUR INVOR _ATION"
BUIING ADDRESS: CITY OF CUPERTINO PERMIT"003060118
Q784 WTNTPRr_RRRN DR
OWNER'S NAME: PERMIT ISUEDN7'G 7/2 0 0 3
TY OF rTTPPRTTNC)
SANITARY NO. 1 CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
300 LICENSED CONIRACIOR'S DECLARATION Job Description
1 hereby affirm Nat 1 am limesed under provisions of Chapter 9(commencing P
n�1 with Section 7000)of Division Sof lee Buvacss mad Preload..Code,and my he..is
a in fullfmmandeBect. NEW RESTRM (WILSON PARK)
License Clan Uc.A
7 Date Contractor
ARCHITECTS DECLARATION
1 understand my plus°hail M used As public mcorde
5 U
s ad Licensed Professional
y OWNER-BUILDER DECLARATION
F 1 hereby affirm that I am exempt from the ConuantorS License Law for the
po following mason.(Sued.7031.5.Business And Prefuaion Cat:Any city ar county
5$ which mGuima a permit to coaslNcl.Aller,improve.dcmnlWl.M mpair any,troemm
_2r�^ prior In is issuance.also requires the Applicant for such permit to role a signed statement
< Nal heI.licensed Fomuenttothe Provisions ofthe cmrneww'.U...LAW(Chapter 9 Sq. Ft. Floor Area
$156VpI3tlltlon
FJ � (commencing with Section 70X)of Division 3 of the Business and Professions Cade)or
it
that he h exempt therefrom and Ne bash fm the alleged exempBm.Any violation of
Section 7031.5 by any Applicant for a pemduubjecs the applicant o•Civil penally of 3 A9N0Q9lPoer 0 0 Occupancy e
nal more than ftw hundred dollars(5500). m P Y 1YP
❑I,as owneraftm progeny,Or my cmployces with wages u theinole Compensation,
will do the work and immature is Act Intended oneffttnd fm sale(5«.7X4,Business
end Profession Code:no Contractor'sLicame LAW does not apply m an owner of 10 2 - PIERS d Inspections
property who builds or improves; eo
thern,and who dons inch work himseif ar Uuough h4
own employment,provided that such improwmems art not intended oraffered for sale.If. 103 — UFER
howewr,the building or improvement is sold within one year of completion.the owner.
budder will how time burden of pro ring that Im did not build or Improve:he purpose of 104 — REBAR
asle')' 105 - ANCHOR BOLTS
I.As owner at the property,Am exclusively contracting with licensed contractor,to 106 — SEWER & WATER
con me,the project(Sec.7014,Business and Profuct.Code:)The Commerce,U
ren¢Lew dos not apply m in owner of property who build+or improves thereon,and 202 - UNDERFLOOR PLUMBING
who contras for such projects with A contaamoKa)licanned pussuant m the Conu mete '
LlmnseLaw. 203 - UNDERFLOOR MECHANICAL
❑l Am exempt under Sec. BRPCfadus. 204 - UNDERFLOOR FRAME
Gw ' �n ,� -- <-/r (o ! 0 205 - UNDERFLOOR INSULATION
WORKER'S CO ENS ON DECLAR,JON
301 = ROUGH PLUMBING
1 hammy affirm under penally of perjury am of the following dClalallON:
haw and will Maintain ACammnite of Consent self-iosam for Wmkerscompem 302 — TUB & OR SHOWER
tabun,As provided fm by Section 3700 at the Labor Code,fm the performance of the 303 - ROUGH MECHANICAL
work for which thisperm(usissued. 304 - ROUGH ELECTRICAL
❑l haw and will maintain Workees Compensation Insuremx.as required by Section 305 FRAME
3700 of Ne Labor Code,for mm perfo.....f the work fmwhich this permit Is Issued.
My Wmkeea Campenudon lnsannCe Cartier and Policy mummer am: 306 — HOLDOWNS
Carrier: Policy No.; 307 - INSULATION
CERTIFICATE OF EX EMP ION FROM WORKERS
COMPENSATION INSURANCE 308 - SHEETROCK
(This section need not hecompleted it the permit is finenc hundred do11an(SI0) 309 - EXTERIOR LATH
°`less') 310 - INTERIOR LATH
1 Certify that in me performance of the work for which this permit is issued.I shall not 311 - SCRATCH COAT
employ any person in any munerw As to bumme subject to theworkeri Comp motion
Laws amisD,¢
Applicant
313 - ROOF NAIL
NOTICE TO APPLICANT.WorkIf.er's
after making previsions Cenino of Excmptiodyou.you mord 501 - FINAL ELECTRICAL ENERGY
,� become aubjM omply it Wohero Coons onion ermtfmm Lahr witad. run 502 - FINAL PLUMBING ENERGY
forthwith comply with such Provisions or this Permit M dcemrA mwkcd.
zo CONSfRUC10NLENDINGAOENCY 503 - FINAL MECHANICAL ENERGY
I hammy Eiren vel them is A cantroction lending agency Cor the Performance tar 504 - FINAL BUILDING ENERGY
z r thor which thhpertnitisisswd(Scc.3097.Civ.C.)
]3 Lender'sader's Name 505 - FINAL ELECTRICAL
Q
�Z LndrsAdamas 506 - GAS TEST
p 1 certify that I have rad this applicAdan and sum that the remove information is 507 - FINAL PLUMBING
cont 1 agme to comply with all city and County ordinances and sum[am mlaling to
building cotswetion.and hereby authorim representatives ofthis city to Amur upon the FINAL MECHANICAL
'have-mentioned property for inspection Purposes. O9 FIN
(We)agree m save,indemnify and keep harmless the City of Cupertino against
.wy liabilities judgmcna.costs and expenses which may ist my my amme,against said City I NG
J 7 in consequence of the granting of this permit.
r� APPLICANT UNDERSTANDS ANR WILL COMPLY WITH ALL NON-POINT Issued by:5 WORKS Date
SOURC EGULATIONS.
-7
Of 2a Sge2;r Re-roofs
nature of Applicam✓Conlrecmr D
HAZARDOUS MATERIALS ISCLOSURE Type of Roof
Will mm applicant m futurebuilding amupenumm m Mbrdle hasArdous nummil
as defined by the Cupertino Mu Ipel Code,Chapter 9.12,and the HeaIN and Safely
.Section 15532(+)? „�e All roofs shall be inspected prior to any roofing material being installed.
❑Yr. Na
Will the applicant or future building occupant use equipment or device which
If a roof is installed without first obtaining an inspection,I agree to remove
hvardnua Air comnminam defined by the Bay Arta Air Quality MaAA,,amV1 all new materials for inspection.
aria?
oyes ❑
I new mad the Interaction,..data nquiarre sunder Chapter 6.95 of the Califon
nia Health A Safely Code,Seeliom 25505.25533 and 15534.1 unrlenund leu if dee building
does net comedy have A males,amt it h mspoesihilimy m badly the aceupua of the
req ice which must bpri
e met oA m r b once ala CcrtiOcam of Occupency6�� Signature of Applicant Date
Owner unushorized agent , All roof coverings to be Class"B"or better �/
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