02100203 (2) CITY OF CUPERTINO a
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:e..
BI.HEsWEEPIZOSE PL MAM DESIGN CENTER INC PERMITNO2100203
9
IIY9PnIC:LEY BRUCE C AND JOYCE M 1676 MONTEREY HIGHWAY APPLICATIPVY"TY2002
PHONE: (408) 298-8668 SANITARY N0. CONTROL NO.
ARCHfIECTIENGINEER: BUILDING PERMIT INFO
BLDG EI.ECf PLUMB MECH
O't LICENSED CONTRACTOR'S DECLARATION
° Job Description
1 hereby alfirm that 1 am( itlicensed under provisions of Chapter 9(commencing BATHRM REMODEL P
with Scntion7( Ilof Div um of thea c anJ Pr..a...ona Codo,ann in larsaa
in full force effcc ''�Tj/
qZ Lovense CI s LirM
° es W Data Co acle "I
roil--oi qqARCHITECTS
nderstandmyplansshallMux public cords a Lf
Faa
LL 8 O Licensed Pmfeasional ).
w OWNER-BUILDER DECLARATION 1'
¢� f I hereby affirm that 1 am exempt from the Contractors Licenx Law f 5't i Y $5500
i S O° following rcamn.(Section]031.5.Business and Pmfcssions Code.Any city or
a�$ which requires o permit to construct,alter,improve,demolish,or repair any structure
'^ pnnnniLs issuance.also requires the applicant lir sucA permiun lilcasigned statement
That he is licensed pursuant to the provisions or the Contractors License Law(Chapter 9 3� Valuation
$�$ (commencing with Section 7Mg))of Division 3 of the Business and Professions Costa)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of I UAPN N Occupancy Type
not more than five hundred dollen($500). 102 — PIERS
❑1,ss owner of the property,or my employees with wages as their wile compensation, 1:83 UPER
will do Ne work,and Ne structure is not intended or offered for sale(Sec.7044.Business
and Professions Code:The Comin lm'a License Law does not apply to an owner of 104 - REBAR Required Inspections
property who s thereon,Wildsor improveeon,andwho doessuch work himself or through his
own employees,provided that uch improvements an not intended or offered(mule.If. 105 — ANCHOR BOLTS
however.the building or improvement is sold within one year ofcomplerion,the owner. 106 — SEWER & WATER
builder will have the burden of proving that he did not build or improve for purpose of
sale.), 202 - UNDERFLOOR PLUMBING
C]1,as owner or the propeny.em exclusively contracting with licensed contractors to 203 - UNDERFLOOR MECHANICAL
construct the project(See.7044,Business and Professions Code:)The Conuacmr's Li.
cense law does not apply to an owner of property who bunds or improvers themes.and 204 - UNDERFLOOR FRAME
who contracts for such projects with a amntractorU)licensed pursuanuo the Cmarxror's'
License Law. 205 — UNDERFLOOR INSULATION
C] I am exempt under Sac, .B&P C for This maxon 301 - ROUGH PLUMBING
er Date 302 - TUB & OR SHOWER
WORKER'S COMPENSATION DECLARATION 303 - ROUGH MECHANICAL
I hereby of ndo under penalty of perjury one of the following declarations: �p 4 — ROUGH ELECTRICAL
❑ 1haw and will maintainsCenifcatcofConxnOoxlf-insumforWoskeflCompem 3b5 — FRAME
nation,as provided for by Section 37r0 of the Labor Code,for the perinrmanee of the
work for which this permit is human. tt 306 - HOLDOWNS
❑1 have and will maintain Worker's Compensation Insurance,u required by Section 307 - INSULATION
3700of the labor Cade,far the performance mewoh for Which this permit is issued.
My We, Compo .tion ms cc cam d otic, YO kD 308 - SHEETROCK
P No.: J 309 - EXTERIOR LATH
CERTIFICCOMPENSATI INSURANCEATE OF ESE N FROM ORKERS' 310 — INTERIOR LATH
fnisxaionnadnothecttmplewdifdtepermirisfnronchundnddnllan(SIW) 311 - SCRATCH COAT
orless.) 313 - ROOF NAIL
1 cattily that in the Performance or the work for which this permit is issued,I shall not 501 - FINAL ELECTRICAL ENERGY
employ any person in any manner so as to become subject to the Workers Compensation
Laws of California.Date 502 - FINAL PLUMBING ENERGY
Applicant
NOTICE TO APPLICANT:If,after making this Cerificam of Exemption,you shouln 503 - FINAL MECHANICAL ENERGY
Iccome subject to Worker's Ccurr maim.provisions critic labor Code.you must 504 - FINAL BUILDING ENERGY
Z forthwith comply with such provisions or this permit shall M deemed revoked.
O 505 - FINAL ELECTRICAL
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of 506 - GAS TEST
Ix > thework for which this permiIisissued(Sac.3097,Civ.C.) 507 - FINAL PLUMBING
Q a;a Name 508 - FINAL MECHANICAL
a U ser:a Address
U O arat1 amiify that I have mad this application and sum that the above information is 509 - FINAL GRADE
canon,I agree to comply with all city and county ordinances and state laws relating to
QU building construction.and hereby authoriva representatives of Nis city Inciter upon the 5 FINAL PLANNING
W show-mentionedpmpeny for inspectionpurpexs. 14 — FIN L I CA W 0 R K S
C (We)agrea m save,indemnify and keep harmless the City of Cupertino against
zy liabilities,judgments,costs andespenses which may in any way ecerw ag,inslsaid City
U w+ APPLICin eNT U NDERSTANDSnce of the grabling of IPermit.his
AND WILL COMPLY WITH ILL N -POINT Issued by: Date
5 U EGULA Ns.
Re-roofs
Sigmamrci f Applican/Comr-on m Type of Roof
HAZARDOUS MATERIALS DI E
Will the applicant or future building occupant son orhanJlehvm
ardsmormd.l
defined by the Cupertino Munictp c,Chapter 9.12.and the Health end Safety
e,Section 25532(a). All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
Will the applicant or luwre bis' Ing occupem use cquipmenl or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit harallous air contaminants cfineJ by the Bey Area Air Quality Mariagcmcnl all new materials for inspection.
a it
ha
❑Yes No
1 haus read me humorous materials requirements under Chap coli 95 of the Califnry
ria Health&Safcty Code,Sevaom 255415,25533 and 25574,1 understand that if the Molding
does not cmrendy have a mnanL Net iI is my rcspnnsihil ly m notify the oecupent or me
myu' Lawbehmu malpncrmissaanmor.Ca ca��n' piney. Signature of Applicant Date
a,to agent Datc All roof coverings to be Class oBo or better