02100061 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR°INFORMATION.
Bulrg7lyf5)AI71Stn.sN WOLFE RD PERMITNO2100061
F,A'R9N NGO, SANDHILL PROPERTIES APPLICAT215S// //"TB 2002
PHONE: SANITARY NO. CONTROL NO.
ARCHITEC 'EENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC.
�Op LICENSED CONTRACTOR'S DECLARATION O
I herebyof irm that I am licensed underprovisions of Chapter 9(commencing [[oo Crl l ❑
d. with Section70khmDivision3oftheBmincssalPntfessionsCodc.andmylicenseis TENANT IMPROVEM g p
��n. is f.11 force and effect. MAy 2 8 2003
j License Class Lic.t
OZ0 Dam Cuntmctm
FM ARCH ECPSDECLARAoON pry�,�T
I understand my plans shall bo used as P.hire records �'L0r.O�
aOaU
LLO Licensed Professional
OWNER-BUILDER DECLARATION
u�<F 1 hereby affirm that 1 am exempt from the Contractor's License Low for the $60000
_p O following reason.(Section 7(131.5,Business and Pnrfessions Codc:Any city or county
$a� which requires a permit to construct,alter,improve,demolish.Or repair any.aruchim
io prier U)its issuunce,also requires the applicant for Such permit to file a signed statement
�Z< that he is licensed pursuant it)the provisions of the Contractor's License Lrw(Chaptcr 9 3*6EIMff YA@m Valuation
,�Q (commencing with Section 7011)of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the allege)exemption.Any violation of
Section 703 1.5 by any applicant for a permit subjects the applicant o a civil penalty of IUAPNN Occupancy Type
not more than five hundred delta.(55110). 102 PIERS
p y yp
0 1,as owner of the preperly,or my employees with wages as their sole compensation,
will do the work,and Ne structure is not intended or offered for sale(Sec.70,14,Business
and Professions Code:The Contractors License Law does not apply to an owner of 104 — REBAR Required Inspections
property who builds or improves thereon,and whodoes such work himself or through his
Own employees,frowned char such improvements are not intended oro0ered forsole.If, 105 — ANCHOR BOLTS
however,On building or improvement is sold within one year orcompletion,the owner-
builder will have the burden Of proving that he did not build or improve for purpose of 106 - SEWER & WATER
gala')' 202 - UNDERFLOOR PLUMBING
pir1.as Owner of the properly am exclusively contracting with licensed contructors to 203 - UNDERFLOOR MECHANICAL
construct the pmject(Sec.7040 Business and Professions Cade)The Comreclues Li-
censeLaw does not apply toanowner ofpmperlywho Wilds orimprom sthemon,and. 204 - UNDERFLOOR FRAME
LicenseLma. rsuchpmjectswithacomanor(s7lian tlpursuennotheCan titers 205 - UNDERFLOOR INSULATION
J.lam azdel Sec. .B&P'C�Sf�opr this f tr—eayson 301 - ROUGH PLUMBING
net na¢yLL-pf vr, 302 - TUB & OR SHOWER
W R'S COMPENSATION DECI,�^TION 303 - ROUGH MECHANICAL
I hereby affirm under Penalty of Perjury one ofthe following declarations: 304 — ROUGH ELECTRICAL
❑1 have and will maintain a Cenlfcate o(Coment to self-iorom for Worker's Compere
sation,as provided for by Section 3710 of the Labor Code,for the performance of the 305 — FRAME
work for which this Permit is issued. 306 — HOLDOWNS
❑ I have and will maintain Worker's Compensation Insurance,v required by Section 3 07 - INSULATION
3700 of Ne Lahr Code,for the Performance of the work for which this Permit is issued.
My Workers Compensation Insurance carrier and Policy number art: 308 — SHEETROCK
Carrier: Policy No.: 309 - EXTERIOR LATH
CCRTIFICCOMP17NSATION INSURANCE WORKERS'
310 — INTERIOR LATH
Conseactirm neednot Mcompleted ifthefermitti(crane hundmedullars($110) 311 - SCRATCH COAT
"rlCAr) 313 - ROOF NAIL
1 certify Not in the perform rice of the work for which this Permit is issued.I abut]not 5 01 - FINAL ELECTRICAL ENERGY
employ any Person in any�rpiaer sn Tel otoPsuhjen to the Workers CuriNdadmir —
LawsafCalifornia.pl�tol/" O U!i 502 FINAL PLUMBING ENERGY
NPOTIC^ APPLICANT.IAe3L tar making this Certificate of Exemption,you should 503 - FINAL MECHANICAL ENERGY
Mea a I5t meWorkcr'sCompensationpmvisionsOfthelsMuCode,YOUMust 504 - FINAL BUILDING .ENERGY
OZforthwith comply with such provisions or this Permit shall be deemed mvnked.
ZO CONSTRUCTION LENDING AGENCY
505 - FINAL ELECTRICAL
.Ni Ihereh allirmthatthemisac,air uchonlendin agency for Irmane of 506 - GAS TEST
F hi g .) Y per tr
FG ti the work for which this Permit is issued(Sec.30y97,Civ.C.) 507 - FINAL PLUMBING
fat 25 lender's Name
Uder'1Address 508 - FINAL MECHANICAL
U O 1 ttnee o comply I have read this application and dime mat the shove ws relating ix 5 0 9 - FINAL GRADE
0U asncalagreetorm.andwith
rch,mcity and county
ntativncesand itytontrcpengto 5 FINAL PLANNING
Q buildingttioned iemantl herehyouthonprposesemmives ofmsscitymentorurym me
uhove-(We)agree
for inspection keep harmless
a
iindemnify14 - FIN IC W RKS
(We)gme to save, and keep harmless me City of against against
N
liabilities judgments,costs and expenses thisPermit.
may in any way accrue against said City
U z A APPLICANT
of UNDEROc STANDS
Of this pfrmll.
r4 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU ;GUhATIONS. O
e Re-roofs
Signature of Appli an ntractnr Dam
RDOUS MATERIALS DISCLOSURE Type of Roof
Will the app¢am or future building occupied store or handle hanrduus mammal
efined by Ne Cupertino Municipal Casae,Chapter 9.11,and Ne Health and Safety
+ e.Salton zss31(an - All roofs shall be inspected prior to any roofing material being installed.
t,,.. cYcx No
Will the applicant of future building Occupant use equipment Or devices which If a roof is installed without first obtaining an inspection, 1 agree to remove
emit hmardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes ANo
I have read the onordoes materials requirements under Chapter 6,95 of the Fabler
dies not
entry haw
a tenannshat if is
rcapJ25534.1 to notify t thmifmc b of(lig
Jtns not currently M1ava a renam,that it is my respumihility to notify the mcuPent of the
rc U likhromiturampriunnodameafactair, x acapancy. Signature of Applicant Date
All roof coverings to be Class"B" or better
tuner or amhm r.cJ cm
Date