03020056 (3) CIBUILDING DI ESIONNO `I ONTRACTOR INFORMATTO
PERMIT
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: APPLICATIO U RAW56
NE: SANITARYNO. CONTROLNO.
ARCHITECTMNGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
e I� E Q
+s ore LICENSED CONTRACTOR'S DECLARATION lob Descrl tion
Y I hereby of om that I am licensed under previsions of Chapter 9(commencing p
with Section 70(10)of Division 3 of the Business and ProfessionsCodc.and my license b
In F'N I
lbw
'^ fill force and effect. l�
Roz License Class Lde.g REPLACE WINDOW
Da Contractor FEB 2 4. 2003
ARCHITECTSCon DECLARATION
1 mWcrsund my pixels that]w used u public records
3 ] Licensed Pmfessi...I
OWNER-BUILDER DECLARATION BUILDING
0 f I hereby.flumsec on11 1. exempt from Ise Cortins Co License Law for the
ipO followingmown.Permit
7onstru Business and Professions Code:Any city.1 county
u�$(v which rcylrta n permit to construct,alter,improve,h permit t or repair any twment
F- a tprior 10 hatheitsusuancc,atsoravimnw anions of for thesuchpctor'lLicero file Law ed(Chapter
�a that he is llanseJ pursuant the previsions of the Camncwr1 Licenxe Lew(ChaPter9 Sq.Ft. Floor Area $1 EI@bgion
$ (commencing with Section7(1(11I)of Division 3 of the Business and Professions Code)or
Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of
Sectionot 7031.5
re vs�dlpcdli applifar a cator subjects the applicant to a civil penalty of 33WI9IDShef 00 Occupancy Type
❑1,asowoerofthepmMny.mmyemployceswithwagnuthedralecompenudan,
will do the work,and thearucture h not intended oroffered forule(Sec.7Wa,Business 101 — OUNDP ��Td IDSpeCt10OS
and Professions Code:The Contractor's License Law does but apply to an owner of
propertywho builds orimprows Nemo,and whodoessuch work himselfor through his 102 - PIERS
ownemployat,provided that such improvements areal Intended or offered formula.It, 103 — UFER
however.the building or improvement Is sold within off year of completion,the awner-
builder will have tite burden of proving that he did not build m Improve for purpose of 10 4 — REBAR
sate.).
01.as owner of the property,am exclusively contracting with parol contractors to 105 - ANCHOR BOLTS
construct the project(Sec.7W,Business and Professions Code:)Due Conocmis Li. 106 — SEWER & WATER
ani Law dean at apply to an owner of property who wilds or improves Nears,and, ZOZ — UNDERFLOOR PLUMBING
who contracts for such pmjecm with a conussor(s)licensed pursuant m the Contractor's
License Law. 203 - UNDERFLOOR MECHANICAL
❑lam assns dm5 .B&PCfar this recon
204 - UNDERFLOOR FRAME
r RKE ' r M ATIONDECLARAate b�l�r0 205 - UNDERFLOOR INSULATION
1 n y aRnm under penalty of perjury off.f the following JalwOor¢
301 — ROUGH PLUMBING
❑1"wand will maintains CartiBCIte.fComem to self-insum far .Workers Compere 302 — TUB & OR SHOWER
cation,as provided for by Section 37M of do Labor Cade,for the peffosmarc a of the 303 - ROUGH MECHANICAL
work for which this permit is banned.
❑1 baa and will maintain Workers Compensation Insurance,u required by Section 304 - ROUGH ELECTRICAL
37M of the LaborCode,for the performance of the work for which this permit is ismsed. 305 — FRAME
My Workers Compensation Insurance carder and Policy number am: 306 — HOLDOWNS
Carder: Policy No.: _
CERTIFICATE OF EKEMMON FROM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK "
Of Ie34) a
(ITIS section acedl be completed if die permit Is for one hundred dellan(gIIX) 309 — EXTERIOR LATH
1 cenify thn in the p once of the work for which this Permit Is issued,I shall not 310 — INTERIOR LATH
emPloyany person Ir�m er veto 12 �s�p iso the Workcn'Compensation .311 — SCRATCH COAT
Law.of mif s am
A PI¢ 313 - ROOF NAIL
N TG LICAN :If,ef aki this Certificate or Exemption.you should 501 FINAL ELECTRICAL ENERGY
Man
a c w the worker's C Penn]on provisions of the Labor Code,you must
OZ rtallowheo IywithsuchProvlawasorthisPermitshauwdeemedrevoked. 502 — FINAL PLUMBING ENERGY
?0 CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
t•+rN. I hereby.firm this there to construction lending agency for the Performance of _
C> the work to,which thus parch isiasad(Sec.3097,Civ.C.) 504 FINAL BUILDING ENERGY
w p
Lender's Name 505 - FINAL ELECTRICAL
�Z LamtersAddmss 506 - GAS TEST
U 0 I certify that 1 have mad this application and more that the be.information is
1, correct.I agree w comply with all city and county ordinanaa and sure laws relating to 507 - FINAL PLUMBING
0 U building convection,and hereby authorize representatives of this city to enter upon the FIN MEC ICAL
ITt ah.w.ona tinned property for Inspection purposes.
(We)agree to save,indemnify and kap harmless the City of Cupertino against 09 F I
N Ilabiitiesjudgments.costs and expenses which may in anyway accrue against said City
U 7 in conangaaeof the grating.(this Permit. Issued
NG
�7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:5 C WORKS Date
SOUR U TIONS. l
Re-roofs
goal o(ApPli nmec r Dow
AZARD S MATERIALS DISCLOSURE Type of Roof
Will the applicant sir(inure bulling e,Chapter
of handle heuNoua maunal
u OeOnW by do Cuaninn Municipal Code,Chapter 9.12,mJ the Health and safely
Code.Sambn 25532(.)? "u All roofs shall be inspected prior to any roofing material being installed.
❑Yet q�"
Will the applicant or future wilding occupant saw cyuipmcni or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emb haxslnus air contaminants u defined by the Bay Arta Air Quality Management all new materials for inspection.
Dinrin7
❑Yes
I have reed thebarardrwsmawrlalsmquimmentsnnder Chapwr6.95ofthe Califor-
- -
ndaNul Safcly Cade,Snduns 25505,25533wd25534.l undcnund dim lfthc wilding
03
�xrtxa�
currently ham a tenant.that it is my responsibility m nod' Isemnup tathe
se .at m l toissuanaofaCcnficamo� Signature of Applicant Date
age Data All roof coverings to be Class "B" or better