03040078 (3) CITY OF CUPEWrINO
BUILDING DIVISION PERMIT C0NTRACTO, RINFORM, 40 .
RUI},DINp ADDRFS$.ESTON DR BLOOMFIELD CUSTOM MASONRY PERMITNo.03040078
OW 'KARLSTEN 6471 LITTLE FALLS DR . PERMITLSUBQA�5/2003 .
E' 4083231111 SANITARY N101.4 CONTROL N0.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
±o ii LICENSED CONTRACTOR'S DECLARATION Job Description
I¢ 1 Mreby affirm that I am licensed under provisions Of CMPIer 9(commencing p
< with Section 7")ofDivisionSofNeBusinessandPrurcem.Codc,andmylicense is FIIiB�►L.E®
4 in full farce and c fee ,/ �V Eve
ucenaa clas Lica^ REBUILD FIREPLACE/FOUNDATION
iF Dau Cantr r
FA CTS A ION APR 2 1 2003
I understand my you mail be used u public records
Ya
Licensed Pm(cuianal
OWNER-BUILDER DECLARATION BUILDING
UI DING
C 0 2 I hereby mount.sect Nat 11. exempt from IM fe Contractors License c Law for tM a"w�/ f. 1 Y�rl
p 0 following apeon it t Ro s 5.Business and improve
euirnu Code:Any oily or county
5$ which its imu a permit re construct,alter,applicant
forse,h Permit t or mash any structure
-iy priamns;iccn ma,also ntu,thathe
ovisio soothe Conrutor's Tensele a nednaument
ss<
that heincing and Auction 7 )of Division
of the Contractor's (ChaptersCode) 9 Sq.Ft. Floor Area $y j' I6�IOn
�Fp that he Is exempth Section and the
hasisofr of the Rusinusandon.An vi Code)or
Y
$ Nu io 7 31.5 b them(rom and or baso for be alleged gumption,Any it penalty
of
Section ads more
0.1..any
undredapplicant oll..( ermltmbjecu Ne applieanua aeivil penalty of 39gDj VOIP�er00 Occupancy Type
not more Nan rw hundred Oollan(5500).
0 1,a owner of Ne pmpeny,w my cmploym with wages u Nair rule compensadon,
willdo the worli thesweurt 4nm intended ararfemd fmaak(Sec.7044.Botilusa
and 101 - FOUNDF} jTd Inspections
Profeaaiana u Code:The Commodes License Law does.1 apply an owner of
Property who Wildsorimpmws thercon,and whodoes such work himml(or through his 102 - PIERS
own employees,provided that such improvemenu aro not intended oraReud for tele.If. lO3 — UFER
however,the building or improvement is sold within one year of completion,Ne owner,
builder will have the burden of praying Nat he did not build or improv fter purpose of 104 — REBAR
axle.). 105 - ANCHOR BOLTS
❑L u owner of property..a.Business mod,anelyd
comramins with licensed1 MC Contractor's Li.
i.
contract doesprojectapply toaOwneofproprty who wilds
Ca orOThe Constend.Li 106 — SEWER & WATER
censwho conwdocsootapply man who aofpmpeny whored partum ad sComon,and
. 202 — UNDERFLOOR PLUMBING
who contracts for ouch Projects with a canlncmrta)licensed pursuant m Ne Contramota
Law.
01 am 203 - UNDERFLOOR MECHANICAL
D roue exempt under w
Sec .B&PCfor thisran
204 - UNDERFLOOR FRAME
net Data-
WORKER'S COMPENSATION DECLARATION 205 - UNDERFLOOR INSULATION
I Mmby strum under Penalty of Perjury one of the following declarations: 301 — ROUGH PLUMBING
`
1 haw and will maintain a Certificate o(Consem in self-insure for Wartrts Campcm 302 - TUB & OR SHOWER
sada.,as provided for by Section 3700 of he labor Code,for tax performance of the 303 - ROUGH .MECHANICAL
work for which Nis permit is issued.
0 1 haw and will maintain Workers Compensation iuwarm.as refund by Section 304 - ROUGH ELECTRICAL
3700 of Ne labor Code,for the performance of the wort for which Nis permit is issued. 305 — FRAME
My Workers Compensation lnmnnce carrier and Polity numbe u: v 4 /�t 306 - HOEDOWNS
Cartier CEERTIFICATEOFE%EMPf10NFROM` ORKERS' y ��J� 307 - INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
or Ices.)
(Tho section need not he completed if the permit is for one hundred dollars gI W) 309 - EXTERIOR LATH
1 cenify that in the PaTrOmuue of use work for which this permit is imwd,l shall not 310 .- INTERIOR LATH .
employ any person in any marmot m u m become subject m the Worsen'Compcuation 311 — SCRATCH COAT
Law a of Califamia Date
Applicant 313 - ROOF NAIL
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become subject in the Worker's Compensation provisions or the L mar Cabe,you must
7z forthwith comply with such prnvisinuorthis pcmtiishallbedeemed revoked. 502 — FINAL PLUMBING ENERGY
40
y CONSTRUCf10NLENDING AGENCY 503 - FINAL MECHANICAL ENERGY
I hereby affirm that Non is a construction lending agency for the perrommea of
x > the work far wNbhthis Permitisissued(Sec.30)7.CN,C.) 504 - FINAL BUILDING ENERGY
O snderaName
" 505 - FINAL ELECTRICAL
s Under'sAddret 506 - GAS TEST
rremss
Q I certify Nat I have reed Nis application and suss Nat theabow information o
y coct.Iamettocomplywithallcityandcountyondinaandsoulawsreiningm 507 - FINAL PLUMBING
Vbuilding contraction,and hereby rothnind mpmlcuMiws of Nit city ro enurupan the FIN L MEC ICAL
above-mentioned property for inspection purposes. XTN
tiG (We)agree to saw,indemnify and keep harmlcu the City Or Cupertino against - 0 9 F I
ti rq Ilabit itica,judgmcnu,Com xpcns ich may lm any way eccmc against said City 5 NG
;)7 in cnnoil eco a IinB u(I ' Pc il.
APPLICANT STANDS D W L COMPLY WITH ALL NON POINT Issued by: C WORKSDate
Rc u n Re-roofs
Sgnvurc or ApplicanUContrumr Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant sum or handle harallous material
as donned by de Cupertino Municipal Code.Chapter 9.13.and the Health and Safety
Code,Section 255320)7 All roofs shall be inspected prior to any roofing material being installed.
0Yca �4u
Will the applicant ar future building Occupant use equipment Or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hovordous air conumimanu.0 darned by the Bay Area Air Quality Management all new materials for inspection.
District?
OYet 7k.
I have read tM havadnuamaterlalam uirtm T underChapar6.95ofNeCalifor-
niaHcalN@SafmyC d SOS 3 2553d.l undcrsund thuifNc Wilting
Joos not curremb h c Na u spouibility u artily the oceuput of the
mil u k' met r ancear.CnUruateororcapany. Signature of Applicant Date
ow car at arivadagem ^6 All roof coverings to be Class"B"or better