03030142 (2) CITY OF CUPERTINO �*' �iT'Y ^a'.:T'` "
BUILDING DIVISION PERMIT
�0NTjde1f'OR INFURMATIQ sx
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: - PERMIT LS
NE: SANITARY O. CONTROL NO.
ARC HITECTBNOINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I� 0 0
o O LICENSED CONTRACTOR'S DECLARATION IOb Description
Ir' 1 hereby aMm But[I am Ilan ma under Meriden of Chapter 9(commencing p
]� with Swdon 7")or DlvWon 3 of the Business am Profcmiom Code.and myliceme Is
? in full to=and effect
�b License Ciao Llc.A REWIRE & LIGHTING FINALE
Dale Contracmr r3
ARCHITECTS DECLARATION AI'pl .2 p vloo'3
3 K R O L J
�i 1 understand my plenaAs
shall be used u PUMIc recoma
589
Licensed Professional
OWNER-BUILDER DECLARATION
.� I hereby anirm Net 1 am exempt from Be CMIMMOr't UMW Law foe the BUILDING
0 0 following Masan.(Section 71131.3,Business and Prole cions Cale:Any city or county
$ which mquim a Permit to construct,alter,Impmw,demolish,or Mpoir any structure
prior In its issuance,also requires the applicant for such permit W rile a signed namment
t&o do he is licensed pursuant to the PMASImu of the Canracl.S License Law(Chapter 9 Sq.Ft.Floor Area $2'�Wbtion
$ (commencing with Section 700M.(Divulon 3 of the Businessand Prefeasims Codo)Or
Nal he le exempt racialism and the basis for the alleged exemption Any v101 Won of '
Semon 70315 by any Applicants for a permit Subjects the applicant W a civil penalty of
not mere than five hundred dellen($500). 3 OY ftTl7eF 0 0 Occupancy Type
❑I,u Ownu of the pmpeny,u my employcu with wager u their mle wmpenu0m,
will do the work and the structure bnogmmnded or.ftmed(u We(Sm.7044,Business 101 - FOUNDP � Inspections
and Professions,Code:The Contmi License Law it=not apply W an owner of
propenywho builds or improwa thereon,and whodess•uchworkhimselfor throughhla 102 — PIERS
own employees.pcovmea that such Improvements AM trot Intended.r.Rerea fwule.If. 103 — UFER
however,the Wilding or improvement Is veld within oro year of completion,the Owner-
bullda will Nw the burden of proving Oct he did not bulb or Improv for purpose of 104 - REBAR
sale.).
[:]hu..of to property,am eumdwly convecting with licensed conuanun to 1OS — ANCHOR BOLTS
construct the pmlem(Sec.7o44.Business and Profusion Code:)no Contractor's LI- 106 — SEWER & WATER
wise Lew due.nm apply t.an owner of property,who builds Or improv theeon,and, ,202 — UNDERFLOOR PLUMBING
who contracts far w
such projects with a cvseter(O rs
licensed puuant W the Con=Weg
License law. 203 - UNDERFLOOR MECHANICAL
ppaantefS�e^ BeeCfmthiseuon
D,e'�—�.S—O 204 - UNDERFLOOR FRAME
WORKERFrnMPENSATI�ONDECIA nON 205 - UNDERFLOOR INSULATION
Ihereby.mrmunder penalty ofperjury Mai following declarations: 301 - ROUGH PLUMBING
hew and wlli mdnt•In a Cmaksm,of Consent to self-imurc for Worker's Compen- 302 — TUB & OR SHOWER
on,u m
pmIded for by Section 3700 of the labor Code.for Os,performance of the 303 - ROUGH MECHANICAL
work for which this permlt b issued.
❑1 haw and will maintain Worker's Compensation Income=.u Implied by Section 304 - ROUGH ELECTRICAL
3700ofghe Lobar Code,Lir the parformance of the work Lir which this permit is Issued. 305 - FRAME
IMy Worker's Coopmution Insursnce carrier and Policy number am:
Carrier: Policy No.: 306 - HOLDOWNS
CERTIFICATE OF EXEMPTION FROM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 306 - SHEETROCK
or Ics.)(ThIs Auction reed not la,completed if the perish is fu one hundred dollars(SIM) 309 - EXTERIOR LATH '
1 comfy Jul In the pufemsmn or the work for which this permit ts Issued.I shall Asst 310 INTERIOR LATH
unploymy PuannInny,manner so u W
A or Calf amie, bceome Subjecuoth rker'Carpyenuo 311 - SCRATCH COAT
Lava "-
App •taiiiii I n a 313 - ROOF NAIL
N 7V I PLICANT:If,after maki this Certificate orasemption,you should 501 - FINAL ELECTRICAL ENERGY
become subject se the Worker'•Compenu0on pos idose of Ne Labor Code,y.0 most
.Jz forthwith comply with such pmvwanaorthis Pennhahalea.lOrdeemoolm 502 - FINAL PLUMBING ENERGY
zw CONSIRUCIONLENDING AGENCY 503 - FINAL MECHANICAL ENERGY
f""mow k for which
hWlmitI learo (Sm.30 len sing agency for ghc Perfurmswe of
13: M Newd(uwhichthispermitbissued(Son.RS'l,Civ,C.) 504 - FINAL BUILDING ENERGY
W Ca Lender'rAame 505 - FINAL ELECTRICAL
� z
Lender's 506 - GAS TEST
U Q I comfy that I haw read this application and sure that the abiew Information ts
WEcorrect.las=tocomply with dlcity and countyominrom,and cotelaws matingto 507 - FINAL PLUMBING
building construction,and hereby authorize reprommtives of this city to cnw upon the
Q aMw-mentionW,tosawfor dcomifyan kneeph FIN MEC ICAL
(We)agree to raw,indemnify and kceP humleu the City.(Cupertino against 0 9 FI
..rh liabilities,judgments,core andexpenses which may In any way so=against said City
U 2 In consequence of the granting of this permit, 5 NG
t� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: 5 C WORKSDa[e
SOUR Eau TION ,
tt.�A ii m Re-roofs
um Of pp�ssulcon r / AM
HAZARDOUS MATERIALS DISCLOSURE has Type of Roof
Wu'
the applicant or future building Occupant Gore Or handle arrow mamdal
As
acOned by the Cupenino Muni pal Code.Chapter 9.12,and the Health and Safety
Cole,Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yon Nu
Will the applicant or(over building occupant use equipment or device,which If a roof is installed without first obtaining an inspection,I agree to remove
It hmamnnna air eonteminanu ss toed by the Bay dee Air Qudlty Menagcment all new materiels for inspection.
nficti
❑Yet o
I have mW the huamawmeterials requirements under Chapter6.95 night,Califon
Ida Health&S rmyCude,Scction,25505.25533 and 23534.1 mbros ata Outfits,building
dna not currently haw a um t,that It is my responsibility W notify the occupant or the
c�qmnu whit cont updorWinumb G fmtca wpamy.03 Signature of Applicant Date
o ar kuthorind•gent ✓L JJDow All roof coverings to be Class"B"or better