02120042 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS: PERMIT N0.
22334 CUPERTINO RD 0212 042
OWNER'S NAME: APPLICATION DATE
Ah TESTER JON AND BESILDA FINALED 12SUB 11 2002
IFONE: JAN 0,6 2003 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
giliLDING O O O O
On. LICENSEDCONTRd under
DECLARATION Job Description
FF�{ I hereby affirm that 1 am fthm Bd under provisions of Chapter 9(commencing p
fiE wiNllit) n7d()ofDivixion3ufNeBusinessandPrnfessiomCode.ondmylicenuis REPAIR FL.JOISTS/SUBFL.
�EE in full fnrcc and effect.
O
R n 4 License Class Lie.M 3&V
Dare Comromnr r'� ARCHITECT'S DECLARATION CONTRACTOR: PRIME EXTERMINATORS
Q
ii 8< 1 understand my plans shall W used as public meet&
y6()6V
r Ism LL 0 Licensed Professional
OWNER-BUILDER DECLARATION
t�i e 0 I hereby affirm that 1 1. exempt from the Cssions Cos e:Any c Law for the
uyr a p 0 following reason. etch t IIonstru t,aincss and am.da oli Code-:Any tiny nr county
a�$ which inquires n permit m m.thic alter,impmsu dcmoluh. fie pair any nructum
the,Wor to,licenantt,dur requires thevisto.ant for such MrmittLNcse Lad hapterm
(commencing
incingudpSectiottoKEofDivionsooftheuacmr'aniccnuLaw(Chode)or Sq.Ft. Floor Arca Valuation
$ (cat he is semwith Section Vaud of basis f r the
the ageBusiness ted Proon.Any
vi Code)of $4 0 0 0
Nat he is exempt therefrom and the basis for Ne alleged Gumption.AnY violation of
Section 7031.5 by any applicant for a permit subjects Ne-applicant o a civil penalty of APN Number Occupancy T
not more Nan fnve hundred dnllare(k500y. 32650067 . 00
p y yPe
❑I,as owner of the progeny,or my employees with wages a:their to compensation,
will do the work,and Ne swetum tmot intended or offered for sale(Sec.7004.Business
and limitations Code:The Contractors Liceave law does not apply N an owner of 101 - FOUNDArjlf�*ed Inspections
property who Wildsorimproves thereon,and who deessuch work himselfur therugh his
Own employees.provided that such impromments are not intended or offered for sale.If, 102 — PIERS
however,the Wilding or improvement is sold within one year of completion,the owner, 1O3 — UFER
Wilder will have the burden of poising that he did not Wild or improve for purpose of
som 1. 104 - REBAR
❑I,as Owner of the property,am exclusively contracting with Ifemsed wrdemmn to 105 - ANCHOR BOLTS
construct the pmject(See.7004.Business and predication Cade:)The Contractors Li-
censeLawdoesnotapplytoanownerofprogenywhoWildsorimProvesthemon,and, 106 — SEWER & WATER
who contra for such projects with a comramm(s)licensed pursuant to the Contractors
License Law. 202 - UNDERFLOOR PLUMBING
❑I am exempt under Sec. .B&PC for this mater, 203 - UNDERFLOOR MECHANICAL
Dwner Dare 204 - UNDERFLOOR FRAME
WORKER'S COMPENSATION DECLARATION 205 - UNDERFLOOR INSULATION
I hereby affirm under penally of perjury one of the following declarations: 301 — ROUGH PLUMBING
I have end will maintain a Cenifncam ofConsenuo self-iruurt for WmkeYsConfirm.
7031."M
ion,u Provided for by Seninn 37M of the IoW,Code.for the performance of Om 3 02 — TUB & OR SHOWER
rk( which this Permit is issued. 303 - ROUGH MECHANICAL
I have and will maintain Worker's Compensation Insurance,as required by Section 3 04 - ROUGH ELECTRICAL
of Ne Labor Code.for the performance of the work for which this permit is Issued.yWn305 - FRAME
rtier. PolicyNrt: `�, 3Z ( 306 - HOLDOWNS
C' IPI
COMPENSATION IINSURANCE
ORKBRS' 307 — INSULATION
Mia section neednot W completed ifda:permit is forone hadreddallats(SIM) 308 - SHEETROCK
mleSr.) 309 - EXTERIOR LATH
I ccnify that in the performance of the work for which this permit is Issued.I Nall not 310 - INTERIOR LATH
employ any pcoven in any manner se as N subject Whom subjeco the Workcfa'Compensmion
Laws of California.Dale 311 - SCRATCH COAT
Applicant
NOTICE TO APPLICANT:If,after making this Cenificare of Exemption,you should 313 - ROOF NAIL
become subject to the Worker's Compensation poivisimns of NC Labor Code,you must 501 - FINAL ELECTRICAL ENERGY
OO forthwith comply with such novisimuor this permit shall W deemed mvnked.
z CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
F = Ibrach,am.Lou there isaconstruction lending agency methe Performance of 503 - FINAL MECHANICAL ENERGY
Ix the work for which this permit isissued(See.YN7,Civ.C.) 504 - FINAL BUILDING ENERGY
W 1cndcri Name
]z UndersAdd.. 505 - FINAL ELECTRICAL
fJ o I ccnify that I have mad this application and sure that the shove information is 506 - GAS TEST
(—' correct I agree to comply with all city and county ordinances and Stam laws mixing to
O building construction,and hereby Authorize upcisou imSOfthiscitymcnterupnthe 5 4FINAL PLUMBING
0. above-mentioned property for inspection purposes. 5O8 INWG
L
Ff" (We)agree to sari,indemnify and keep homeless the City of Corona.against
(q liabilities,judgments.costs and expenses which may in any way am.against said City 5 N
in
of W Sminfing of
V^�
APPLICANT eUNDERSTANDStAND WILL COMPLY WITH ALL NON-POINT Issued by$1 Date
SOU� r,$EGULATIQNZ. _
l4;IA a nRe-roofs
ssigrot ain owdiesbuccoustrou Date-
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Neapplicantorfuture building occupant sunt nr handle haw umA material
as defined by the CuNnino Municipal Code.Chapter 9.12,and the HcaIN and Safety
Inia
ode.Section 25312p)7 All roofs shall be inspected prior to an roofing material beim
❑Yea ON. P P y g g installed.
Will the applicant or future building occupant tau equipmcm or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit haruNous air contaminanH as defined by the Bay Arca Air Quality Management all new materials for inspection.
istrict'!
❑Yes ON.
I have mad the haca dmfs materials mqui nnumus under Chap¢r6.95 mine Celifor- 2
Health&SafetyCode,Secdom25505,25533 and 25534.1 un lcusurnd thmiftbe building
ors nen cortically have a tenant,than in is my msWicability to notify the Occupant of Ne
ctaim�ntx �hich mastrg.1pprior At son An On of a certificate of 0`7 Signature of Applicant Date
�C ' " ' (M-7 �'2/1I)x'19 All roof coverings to be Class"B" or better
Owner Or out rived agent Date