02090116 CITY OF CUPERTINO `xY ea "W _• �"' '+
BUILDING DIVISION PERMIT CONTRdACTOWINFORMATI,ON:
But D LIR' WOLFE RD PSIDB, INC PERMITN02090116
RkR,13: ROEBUCK AND CO W2 32 S 7530 BIG BEND DR APPLICAT019SYBIP 2002
PHONE: (262) 662-5551 SANITARY NO. CONTROL NO.
ARCIIITECrIENCINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
0 0 0 0
�0, LICENSED CONTRACTOR'S DECLARATION
ug1 hereby affirm that I am licensed under provisions of Chapter 9 mommcncing TI Job Description
W $amine]qYB fDivixinnJOf Ne Business n ofcuionabsJc.and myliccnsc is
ro�> i
Z O n full Inre nQQfccl. r� Lic.N a.z D 9'63
q Liccnsc lass :L_ ������j_
ffOZ-O 2 02 Cnnuact �i �A IL
iF j ARCHITI[CTS DECLARATION Y '. ` ALE®
�_g w< 1 undersmnJ my plans shall Mused as public remands
dOWU
3a. Licensed Professional APR 2 9 2003
OWNER-BUILDER DECLARATION
<lF I hereby affirm that I am exempt from the Contractor's License Law for the $2187000
a a G O following maxim.(Section 7031.5.Business and Professions Cole:Any city or county
$ which requires a permit to cnnsuucl,alter,improve,demolish.Or repair any structure Rim nikin
r pdorto its issuance.also requires the applicant forsuch Permian Ole asigued statement
H< that he is licensed pursuant to the provisions of the Contractor's License Law(C'hapmr 9 3*61R Valuation
eat (commencing with Section 7B0(R of Division 3 of the Business and Professions Coe)or
-
that he is exempt therefrom and Ne basis for the alleged exemption.Any violation or
Section 7031.5 by any applicant for a pemtit subjects the applicant to a civil penally of PN N Occupancy Type
not more than rive hundred dollars($500). 102 — PIERS p y yp
0 1,is owner of the properly.or my employees with wages of their sole compensation.
will do the work,and the suucmas is not intended or offered for sale(Ses.7W,Business
and Professions Cade:The Contractors License law does an apply N an owner of 104 - REBAR Required Inspections
property who builds or improves thereon,and who doessuch work himself or through his
howemployees,provided that such improvements am not intended or offered far sale.If, 105 - ANCHOR BOLTS
ever.me building or Improvement is sold within one year of completion,the owner- lO6 - SEWER & WATER
builder will have the burden of proving that he did not build or improve for purpose of
role.). 202 - UNDERFLOOR PLUMBING
0 h as owner of the property,am exclusively contracting with licensed contractors to 2 03 - UNDERFLOOR MECHANICAL
construct the project(Sec.7044,Business and Professions Cade:)The Contractor's Li-
ccuse Law does not apply to an owner of property who Wilds or improves themor,and 204 — UNDERFLOOR FRAME
Licenemµufnrsuchpmjecmwithaconuamm(s)licencedpursuanttoNCCCntractori 205 - UNDERFLOOR INSULATION
❑ I am exempt under Sec. ,B&P C factor nation 301 - ROUGH PLUMBING
net Dam 302 - TUB & OR SHOWER
WOR K ER'S COMPENSATIONDECLARATION 303 - ROUGH MECHANICAL
I hereby aRrm under penalty of perjury one of the following dethoulams: 304 - ROUGH ELECTRICAL
I have and will maintain a Certificate nfC...tt mself-insure for Worker's Camped. 3O5 - FRAM}_',,
cation,u provided for by Section 37(10 of the Labor Code,for the performance of the i
wok ler which this permit is issued. 306 — HOLDOWNS
0 1 have and will maintain Worker's Compensation Insurance,as required by ScOun 3 07 - INSULATION
37(11 of the Labor Code,for the performance of the wark for which this permit is lamed.
My worker's Co pensmi sat-lyn/sunnm carrier and Policy nu Mrare: 308 — SHEETROCK
��.'y{sJ!er Sf/�ar.I /�/PPT✓V�PoliryN. Rrt'��—aP� 309 - EXTERIOR LATH
/V CERTIpIC OMPE SATIONINSUR WORKERS'
COMPIiNSATION INSURANCE 310 - INTERIOR LATH
Commotion recd notbecomplmedifthepermitisfonnc hundreddollaninin) 311 - SCRATCH COAT
of 1C5s.) 313 - ROOF NAIL
I certify that in the performance of the work far which Nis permit is issued.1 stall not 501 - FINAL ELECTRICAL ENERGY
employ any person in any manner so as m become suhhet to the Workcrs'Compensation
Laws of California.Date 502 - FINAL PLUMBING ENERGY
Applicant you should 503 - FINAL MECHANICAL ENERGY
NOTICE TO APPLICANT':If,after making this Ccnirim caOf Exemption,y
Mcomcahiect m the Worker's Compensation provisions of the laMr Code.you must 504 - FINAL BUILDING ENERGY
OO forthwith comply with such provisions or this permit shall bodecmcd revoked.
z 505 - FINAL ELECTRICAL
CONSTRUCTION LENDING AGENCY
[-+4 lhereby oceanthat John isaconswctionlending agency liorth.performanceof 506 - GAS TEST
z > me work far which this pttmiIismold(Sce.3097,Civ.C.) 507 - FINAL PLUMBING
fzl Q Learn s Namc
7 Z Iandcr'sAdd.. 508 - FINAL MECHANICAL
U O 1 cenRy that I have Taxol this application and sate that the above information is 509 - FINAL GRADE
H. F corms.Iagree1.complywithallcityandCountyreinancesandsumlawsmintinga. 5 FINAL PLANNING
building construction.and hereby authorise mprese tativcs of this city to enter than the
above mentioned property for inspection purposes.
(We)agree m save,indemnify and keep harmless the City of Cupertino against 14 FIN IC W RKS
ti(n Iiahilitics,judgadmi costs and capenms which may in any way accme against said City I q o
U ,Z in consequence of the granting of this permit.
^� APPLICANT UNDERSTANDS AND WILT.COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGOLA7'IONS. /.7-/2-1c;
a Re-roofs
sere Of Applica i/Conlanor Dam
I IAZARDOUS MATERIALS DISCLOS RE Type of Roof
Will me applicant or forum building occupant sure or handle hasurbas material
defined by the Cupenino Municipal Code,Chapter 9.12,and the Health and Safety
e.section2ss3xa)'! All roofs shall be inspected prior to any roofing material being installed.
❑secs X No
Will the applicant nr future building Occupant..equipment or device,which If a roof is installed without first obtaining an inspection, I agree to remove
emit h,,a mm,air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection. la4
Dlsuictl
0Ycs �No
I have mad the hamNous materials reyuiremcnts under Chapter 6.95 of the Califor-
nia llealN&Safety Coale,Sections 25.815,25573 and 25574.1 undersunJ thio if the
built.,
does not currently have a mean that it is my respmuibility to notify the rccupant Of the
req ui iiswhichmustN,sectpriorminductee ofaC,mr,.mofOempancy..121/ Signature of Applicant Date
owns tmudxeeagcm /!]G_- Date All roof coverings to be Class "B"or better