03090238 (2) CITY OFCUPERTINO
BUILDING DIVISION PERMIT 4CONTRACTOR4NF ,RMATIOON,'
BUILDING ADDRESS: CHARVEZ CONSTRUCTION 1E1MITNo.03090238
'SN ME: 360 W 8TH ST PERMIT ISSUE DATE
PHONE: SANITARY
(408) 893-7693 CONTROL NO.
ARCIIITELT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�00 LICENSED CONTRACT'OR'S DECLARATION
1 hereby affirm the.I am Immortal under provisions of Chapter 9(cummcncing Job Description
z� with Section 700K))Of Division Sar the Bonn...no Prorcssiom Code,nd my license is
in full forte and effect.
_ Lieens,Clasa Lin.0 BATHROOM REMODEL/SERICE UPGRADE
irk Dale Cungecmr
pp ARCHITECTS DECLARATION
WU 1 undcrsunJ my plans shell M recd a public records !/ " ^,t � R
'�<nLicensed ProfessionalOWNER-BUILDER DECLARATION
<f 1 hereby a�Rrm that I am exempt fru.Ne Contractor's License Law for the l
caO following mason.(Beef.710 I.S.Business and Profoseum Cade:Any city or countyFI
S9 which requires a Pewit to Conswct,alter,improve,demolish,or repair any structure )
.zi
pd.,o its i.......Isa rtquiv11C.PPlicantfarach fcroniuo file a signed statement
s`o that he is licensed ptestenun the provisions of the Comrustrums License Law(Chapter 9 Sq. Ft. Floor Area _ Va 9406
2� (commencing with Section 7")of Division 3 of the Business end Profmsinm Code)or
s, that he is exempt therefrom and Ne basis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant Lor a permit subjects the applicauo a civil Penalty of APN Number Occupancy Type
not more than five hundred dollars($500).
❑Las owncrrofthe progeny,or my employee,with cages as their sole campenadon,
will do Ne work,and the structure H not intended oraffched for sale(Sec.7044.Business 101 - FOUNDA)$-AQDid Inspections
and Professions Cade:The Convector's Lice.e Law does not apply to an owner or
property who builds or improves themon,and who doesauch work himselfor through his 102 - PIERS
own employ=,provided that such improvements are not intended or offered posters.If. lO3 — UFER
however.the building or improvement is sold within one you of completion.Ne owner
builder will he.de burden of proving that he did net build or improve for purpose of 104 - REBAR
sale.).
KI,as owner of the progeny,am exclusively contracting with licensed contractors to 105 _ ANCHOR BOLTS
ower the project(Sec.7044,Business and Professions Code:)The Contractor's LI' 106 SEWER & WATER
cense Law docs not apply in an owner of property who Wilds or improv themon,and, 202 - UNDERFLOOR PLUMBING
who contracts for such projects with a contractor(s)r(s)licensed pursuant the Contractor's
LicaLaw. 203 - UNDERFLOOR MECHANICAL
I. aemplu ter c. ,B&P for this aso
Dore 204 - UNDERFLOOR FRAME
WOR e 's OMPENSATI +DecLLA�,�RA�/yION 205 - UNDERFLOOR INSULATION
Ihercby eRnn under peneltyo(peju cenhe fnlTdwmg dedanmm: 301 — ROUGH PLUMBING
❑1 ban And will maintain a Cenifcam of Consent o self-Insure for Worker's Compere 302 — TUB & OR SHOWER
cation,As provided for by Section 37W of Ne Labor Cade,for fie Performance or Ne 3 0 3 - ROUGH MECHANICAL
work for which this permit is issued.
❑I haw and will maintain WOArr'SCOMPemaLlon lmuance,As required by Section 304 - ROUGH ELECTRICAL
37M of NC Labor Code,fat the performance of the work for which this gamut is Issued. 305 — FRAME
My Workers Compensation Insunnce cosier and Policy number are:
306 - HOLDOWNS
Cartier. CERTIFICATE OF EXEMPTION FROM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
(Thi.arednoneed not be completed if the Permit is for one hundred dollars IS 100) 309 - EXTERIOR LATH
or kssJ
I certify that in the performance,of the work for which this Permit is issued.I shall net 3 10 INTERIOR LATH
employ any person in any msomerso As to become subject tothc Wmiferi Comicnadon 311 — SCRATCH COAT
Laws of California.Date
Applicant 313 - ROOF NAIL
NOTICE TO APPLICANT.If.after making this Cenifrcate of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become subject.the Workers Compensation provisiom of fire Labor Code,you must
� Z forthwith comply with such provisions or this Permit shall M deemed revoked. 502 — FINAL PLUMBING ENERGY
ti
CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
I hereby sploo Net there its construction lending agency for the Performance of 504 - FINAL BUILDING ENERGY
Y,
the work fur which this peonit is issued(Sec.3(197,Civ.C.)
z7p Lender's Name 505 - FINAL ELECTRICAL
7Z Lanett'Add.a 506 - GAS TEST
;)0 1 Gentry that I have rad Nis application and seam then she above information is
y f" comet.IagreetocomplywithallcityandcountyoNinamsandsatelawsmixiingm 507 - FINAL PLUMBING
5 V building Construction,and hereby authorise representatives of this city to cmcr upon the FI&&NWG CAL
ehovc (We)Are progeny for Inspection Purposes.
(We)agree to ave,indemnify and trop harmlea the City of Cupertino against FI
to liabilities judgments,costs and expemes which may in any way accme against aid CityZ mcoLoquic oftnc zoah1mgofthisparmit. !09
APPLICA UN ER STAND D WILL COMPLY WIT LL N POINT Issued by: KS Dale /
soP IC R UL IONS.
L- Re-roofs
YgillumfAppliceHAZARDOUSMATRIALSDISCLOSURE m Type of Roof
Will the applicant or rut=building occupant store or handle havndous material
a defined by that Cupenlno Municipal Code.Chapter 9.12.and the Hcalth ad Safety
Bankes 25532007
Yc3 All roofs shall be inspected prior to any roofing material being installed.
� Dg rva
Will the applicant or fuw.building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit humdam air contaminants ex defined by the Bay Area Air Quality Management
District? all new materials for inspection.
❑Yes 91N0
1 have read the haeardrmsmamriais requirements under Chapterti.95 of the Califor.
du Ncalth&S ly ,Seed..25505.25533md25534.lundnwdLhatifNc building
docs not rumeny h a renano at it is my efimnsihility to notify the ram Pal o the
require.enuw ich usl neat sur to i sumcc of a CCmrcamof Rcua Signature of Applicant Date
ow,or uthad,ed agent m All roof coverings to be Class"B" or better