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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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INFIJRNM"OIN
BUILDING ADDRESS:
PERMIT NO. 03090060 3090060
-R'S NAME:
PERMRISSUEDATE
0 2
HE:
SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB
MPRH
LICENSED CONTRACTOR'S DECLARATION
.lob Description
1 hcrcby affirm that l am licenvad under provisions of Chapter 9 (commencing
with Section 7WO) of Division 3 of NC Business and Professions Code, and my license is
in full mmc and effect.
ADD 447 SQ.
FT.
License Class Lic.tl
Dam usedContractor
ARCHITECTS DECLARATION
public
1 undcrsunJ my plans shell he mail a Puhlic rcwNa
is 1 / ✓�
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Licensed
OWNER -BUILDER DECLARATION
affix
hereby Law for he
I hereby affirm on l 1. exempt tram the Casionso Code: Any
following massa 703 Business and Code: Any city or musty
O
ve demolish, or repair any sanctum
which nstr improve
permit m construct,
requires hermit t
h perspit u
Prior m its issuance, also a to the the epplic of for such ra tonin Bre s signed statement
its n applialter.cant
escingwneed PursuantmheorvisionsofheCousines'snimnseLaw (Cotmr9
Sq. Ft.
Floor Area
Valuation
(commencing with Section 788 Division J of the Business and Professions lation or
d the
,at he is evemp(thcntfrom and the baso for he alleged exemption. Any violation of
,at he 1, exempt
36204039.00
APN Number
Occupancy Type
Section 7031.5 by any applicant for a Permit subjects he applicant to a civil penalty of
not more than five hundred dollars (SSW).
0 1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is notinkn@tl oroffered formic (Sec. 7(164, Business
��m++��T
— OUNDNF-1 ;d
and Professions Code: The Conuactor's License law does not apply m an owner of
--^s Inspections
property who builds or improver thereon, and whodoes such work himtalf or through his
10 2
- PIERS
Own employees, provided that such impmvemenu are not intended oroffered forsale. If,
103
— UFER
however. the building or improvement is sold within one year of completion, the owner -
pa ileer will have the burden of proving that be did not build or improve for propose of
104
- REBAR
105
- ANCHOR BOLTS
Ej 1, as owner of Ice property, . R excessively contracting with licensed convenors Li-
l06
— SEWER & WATER
oneject(Sec.706gBuerofsaneProfessionsCaorJ7Teisresumrlu-
cense Law improvhe resume, and
pr onto ownarofproperty whored
202
— UNDERFLOOR PLUMBING
fmet or pursuant
contracts for such projects with a conmector(s) licensed pursuant m me Contractor's
1w1yyh�co
Clean- L,#,
203
- UNDERFLOOR MECHANICAL
nticrSec. B&P ormiareaaon
204
- UNDERFLOOR FRAME
jy
WO ER' OMP ON DECLARAD N `�"�-
205
- UNDERFLOOR INSULATION
I hereby affirm under Penalty of perjury one of the following declarations:
301
— ROUGH PLUMBING
I have and will maintain a ccmncem or consent to smGinnure for worker's ComPen-
302
— TUB & OR SHOWER
u'ion„az provided for by Section 37M of he labor Code, for the Performance of the
303
- ROUGH MECHANICAL
work for which this permit is issued.
304
- ROUGH ELECTRICAL
❑ I have and will maintain Worker's Compensation Insurance, as mounted by Section
37M of Use 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 am:
306
— HOLDOWNS
easier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
307
— INSULATION
COMPENSATION INSURANCE
308
- SHEETROCK
(this section wed our hcomindmed if mit he peris for one hundred do8am(S MM
309
- EXTERIOR LATH
is, less.)
310
— INTERIOR LATH
1 ccnify that in the performance of the work for which this permit is issued, I shall not
employ any person in any marmoso as to become subject o the Workeri Compensation
311
— SCRATCH COAT
Laws o^Cadialigja, Dam
Ap '
313
501
- ROOF NAIL
- FINAL ELECTRICAL ENERGY
CE TO APPLICANT: If, after making this Cenificam of Exemption. you should
bels a subject to the Worker'a Compensation previsions of the Ichor Code, you mere'
forthwith comply with ouch previsions or this Form it shall he deemed revoked.
502
— FINAL PLUMBING ENERGY
CONSTRUCT] ON LENDING AGENCY
503
- FINAL MECHANICAL ENERGY
I hereby M. Nal mere is a consuve'inn lending agency or the performance of
504
- FINAL BUILDING ENERGY
on,workr:s Name for which this permit is issued (Sec. 1097, Civ. C.)
Lender's
505
506
- FINAL ELECTRICAL
- GAS TEST
Leadera Address
1 ccnify Nal l have read his application and some that he above information is
tortenm . 1 agree comply with all city and county ordinances and state laws relating to
507
- FINAL PLUMBING
building construction, and hereby authmim representatives afthiscityto enter upon me
FIN MEC3jCAL
shove-mcntinncd property for ierpection Purposes.
(Wc) agree to save, indemnify and keep harmecss the City of Cepenina against
0 9
FI q
f�U�/
Hemlines, judgments, costs and expenses which may in any way accrue against said City
5
inM41ng of this (mil.
A WILL COMPLY WITH ALL NON-PygJT
Issued by:5
.NG
IANOS
C WORKS Date
Re -roofs
Type of Roof
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l7 q -$—off
Signamrc of ApplicaHA tactor v Dale
HAZARDOUS MATERIALS DISCLOSURE
Will he applicant or !Muni building occupant store or handle
Health anmaterial
az defined by he Cupertino Municipal Code. Chatter 9.11, and the Health and Safety
e.s en ns3zan
All roofs shall be inspected prior to any roofing material being installed.
❑Yes Nu
i
If a roof is installed
without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
n cavardous air com uroments as defined by the Bay Area Air Quality Management
all new materials
for inspection.
lalflcl? /t
❑Yes
1 have mail the havallousmaterialsomuim unuunderChaPmr6.95ofheCalifor-
niaHcalthg:S IyC .Scctium 25NI5.2533 and 255J4.IunJcrsland hssifthc building
'
Vas not en n' aw tenant, mal it is responsibility to noul' the eecupw'sf the
myuim ich the dorm once nfa cmulleate of cy
Signature of Applicant
Date
All roof coverings to be Class "B” or better
O
ro aulhorivedagcnt am