03090169 (2) CITY OF CUPERTINO r
BUILDING DtvlsloN PERMIT .�CONTRACTdR INFORMATION
BUILDING ADDRESS: PERMIT NO.03090169 3O9O169
IMR'S NAME: PERMITISSUEDATE
PIONE; SANITARYNO. CONTR0LN0.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
300
LICENSED CONTRACTORS DECLARATION lob Description
I I hereby affirm that I am licensed under provisions of Chapter 9(commencing /
With Senion]OIM))Of Division]of the Business and Pr.ressium Cade,and mYlicemc is LRLADE/GARAbE
f? .inmltfromandeffe°, WINDOWS UP DOBRP'C GE
License Class Lk.Nig0Date ContractorARCHITECTS DECLARATION
1 undcrsunJ my plane shall M used u public records
)6 GGGYYY tW, /(fes
Licensed Professional 'I
N OWNER-exempt RDE DECLARATION U
0 y I hemhy.(T.m that 1 em exempt from the Cssion lis License c Law for Nc
O O following reason.Permit
ti A°lust Business andimprove.
Profession Cake Any city m county
S g which requires a e.also tit cnmtrum,alcor,impmsu h cm it t fl repair any iat mum
dd-Zy plinr NlLL lIIwnce.also RyYlRathc applieant fnfeneh pClmilw NCa RigncJ slemlllent f
< that he is ticcnsed......unlhepmvisiowofNeCOnuumr.IJcenuLaw(Chapury Sq.Ft. Floor Area Valuation
55 Fps (commencing with Section 7")of Division 3 of the Businum4nd Professions Code)of
r,3
that be Is exempt Ncmfrom and du boo for the Nlcgcd exemption.Any vlo1v0on of 35611006 . 00
Section 7031.5 by any applicant for°permit subjects Ne applicenno a civil penalty or APN Number Occupancy Type
nm more Nan five hundred doll..($500).
❑I.ss owner of the property,or my employees with wages.their sol.campenotion,
wilt do thework.ndth Ormot.is notin¢nded orortered fouam(Sm.7044,Business iol — FoUNNRF
dIDS ecuons
and Professions Code:The Cnnuacure.Lt..law docs nut apply ro an owner of 10 2 - PIERS p
property who builds or improves Neuron,and who doessuch work himmlf or through Ma
Own employees,provided that such improvements are not intended oraBemd forum.It. 1O3 — UFER
howeveq the bung or impmvemem is old wn one yet of compinion,Ne owner-
builder will have the burden or proving Nat he did not build or improve fur purpose or 10 4 - REBAR
`Il`'1. 105 - ANCHOR BOLTS
1,
as owner Of Ne property,am exclusively contracting with licensed connectors to 10 6 - SEWER & WATER
on
Imo the project(Sec.7044,Business and Prorussiona Code)The Contractor's Li-
cemeLawdosnotapplymanownerofpropertywhoWildsorimprovesthemon,and, 202 — UNDERFLOOR PLUMBING
who contract,for such projeN with a==norm licensed pursuant he the Contracmh
Li,eee Law. 203 - UNDERFLOOR MECHANICAL
❑lane e. rSec. ,B&PC for N.m nn 204 - UNDERFLOOR FRAME
°° z; o3 205 - UNDERFLOOR INSULATION
WORK R'SCOMPEN IONDEC T 4 '
I hemby snort under penalty of perjwy one of Ne following de.laratlnw: 301
- ROUGH PLUMBING
❑ In.wantlwiltmeinseroeC,niBcaworConxmmmR-msumforworkncompcn- 302 — TUB & OR SHOWER
.tion,as provided for by Section 3700 of 0,labor Code,for the performance of the 303 - ROUGH MECHANICAL
work for whichthisp.I,I,issued. 304 - ROUGH ELECTRICAL
71 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of due Labor Codc.for du perfarm.ce of Ne work for which Nis permit is issued. 305 — FRAME
My Workers Compensation booms cunmr and Policy number art: 306 — HOLDOWNS
Cartier. PolicCERTIFICATE OFEEXEMPfIONYFROM WORKERS 307 — INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
This section need not W completed if the Monsit is for one hundred dolla.(S Iral) 309 - EXTERIOR LATH
or les)
1 enify that m the perfumn.rc.of the work for which this permit is issued,I shell nut 310 - INTERIOR LATH
employ any permit in any manner an as to become subject o N.Workers'Compensation 311 — SCRATCH COAT.
Laws Of California.pats
Applicant 313 - ROOF NAIL
NOTICE TO APPLICANT:Ir.after making this Certificate of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become subject On the Worker's Comperwtion mvisions,of the labor Code,you most
,JZ forthwith comply withsuch provisions Orthis pconitshall the d.cmedrtw,kd. 502 - FINALPLUMBINGENERGY
zo CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
[=. IherthyeTom that Nemis.cixamominnlending&&cngrnrthepoformance.1 504 - FINAL BUILDING ENERGY
C.> Ncwork for which Nispermit lsissned(See.J(19],Civ.CJ 505 - FINAL ELECTRICAL
{f] 0 Lenticr's N.mc
z Le d, Md. 506 - GAS TEST
U O 1 certify that 1 have mad this application and sum Net the above inromu0un Is 507 - FINAL PLUMBING
Fcorrect.l&&rte to comply with all city and county ordinances and sum laws misting to
C) U building construction.and hereby sudeorm reprtmntatiw of this city to enter upon the FIN iMgCAL
L37 shove-mentioned pmpcny for inspection purposes.
(We)egme m sets,indemnify and kap harmless the City or Cupertino against V09 F IN liab111d.judgments.costs andsales.whichmayinanywaysecrwagairutsaidCity NG
U Z in mosectepe of N=gunting of this permit.APPLICA UNDERSTANDS AND WILL COMPLY WITON-PO Issued bY: WORKS Date
Dp GG DN a o 3
Re-roofs
ignature of ApplicantlConwcmr Dat
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or Pomm sodding uccupanumm or handl,hayardow material
dc0ncd by Inc Cuperllnu Municipal Code.Chapter 9.12,end the Health end Safety
.Secti .25532(.)7All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
Will the applicant or future building occupant use equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hamdow air contaminants as declined by the Bay Area Air Quality Management all new materials for inspection.
District?
OYes , Nu
I have mW Ne hweNtms materials requirements urccr Chapter 6.95 of du Califon
nia Health&Safety Code,Secuons25705,25533od255J4.lun&nwdNatifde building
Jas nosy a un t,Net itis my rtspowlhility m noul'y N,acupant n( c
m Ins m, as
etpri.r.sounc,.r.c,mBe�egr ptpNclil 0 Signature of Applicant Date '
Owner of authodmd agent 'pa6ts All roof coverings to be Class"B" or better