03070200 (2) CITY OF CUPER'1'INOz
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:"'
BUILDINCADDRESS: KL CONSTRUCTION PERMIT NO 03070200
ERS NAME: 322 PERRYMONT AVE PERMIT ISSUE DATE
PAUT, PARK 07/29/2()03
F oNE: (408) 989-9650 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
+oo LICENSED CONTRACTOR'S DECLARATION �7 O O O
LwF 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
'S ZIy with Sccda�]0�1qpj� cion Jyrthc Busin an rofcssiuns Codc,andmyliccoscis
'may in fullfomea�d cf��'f.i���'1�lI� � �
eqz LieenseCJa¢fyLk. REVISION--IN HOUSE USE ONLY
ARCIIITECTSD c` RATION NO NEW PERMIT ISSUED/ORIG. # 03050019
Irc Ilocursundm sshall unlit Js
any Licensed Professional
OWNER-BUILDER DECLARATION
<E 1 hereby affirm that 1 am eac.pt fru.Ne Convenor's License Law for the �\
O O following reason,(SceOnn 7131.5,Business and Profession Codc:Any city or county
<m ii. which exPa es a permit to emotnuch alter,improve,demolish,or mpor any st.tu.
^iy poor In its issuance.also requires the applicant for such Permit to file a signed statement
gin that he is licensed Pursuant to the provisions of the Contractor's LicenuLaw(Chapter 9 Sq.Ft. Floor Area luatio$107
(commencing with Section 7")of Division 3 of the B uviness and Profession Code)or
c R_ that he u exempt themfrom and the buts for the alleged exemption.Any violation Of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 A2111.Mila Ber O O
not moOccupancy Type
le than rive hundred dollen(M).
1,as owner of the proper",o my employees with wages as their sole compensation,
will do die work,and the structure is not intended or offered for sale(See.7044,Business
and Professions Code:The Contractor's Licnne Law does WE• I to an owner of I��{� p d Inspections
property who builds or improves thereon,and who doessuch work himself or himself his 101 - FOUNDA
own employees.provided that such improvements see not intended or offered for sale.If, 102 — PIERS
however.the Wilding or improvement is sold within one year of completion.the owner-
builder will have the Wrden of proving that he did not Wild or improve for purpose of 103 - UFER
01. 104 - REBAR
❑ I.as tester of Ne property,am exclusively contracting with licensedcontractorsi-
construct me projm(sec.7044,Bus{nest and P.fcssions Code:>The Convector's u- 105 — ANCHOR BOLTS
ccae Law don not apply to an Owner of property who Wilds or improve thereon.and 106 — SEWER & WATER '
who contracts for such projects with a convanor(s)licensed pursuant o the Convaaofs
El Law.
❑lam un exempt under sec. ,Bit PCfor this - UNDERFLOOR PLUMBINGis mon 203 - UNDERFLOOR MECHANICAL
Door 204 - UNDERFLOOR FRAME
WORKER'S COMPENSATION DECLARATION
Ihereby af ran under Penalty of perjury one of the following declarations: 205 - UNDERFLOOR INSULATION
❑I ham and will maintain a Cenileae of Consent to self-inum for WorkefsCompcn- 301 — ROUGH PLUMBING
swu n,as provided for by Section 3700 of the UWr Code,for the performance of the 3 02 - TUB & OR SHOWER
work for which this permit is issued.
❑I ham and will maintain Worker's Compensation Insurance,ss required by Section 303 - ROUGH MECHANICAL
37M of theUbe,Code.for the pmformaite of thegorksTnr which mea Permit ix inured. 304 - ROUGH ELECTRICAL
My WorY,e's Cn pronation Incur n<c carticr end.P/o��/ umber art'
�y 9 305 - FRAME
Ld7nV: l�gr. Policy No.:.sy�_],� 306 - HOEDOWNS
V CER] FI EOFEXEMPr10N FB61 rORKERS— —
COMPENSATIONINSURANCE 307 - INSULATION
Icsx.7(This section need not be comPlncJ if the peorrom for one hundred dollars($]fkB 308 - SHEETROCK
m
I eenify that in the Performance of the work for which this Permit is issued.)shall not 309 - EXTERIOR LATH
employ any Person in any manner an as to become saheicuo be Wofkeri Compensation 310 — INTERIOR LATH
Laws of California.Dam
Applicant 311 - SCRATCH COAT
NOTICE TO APPLICANT:1f,at making this Cenifutc of Exemption,you should 313 - ROOF NAIL
became withcomplyect the Worker a pm Compensation thinprovisions of themed Coked. mon 501 - FINAL ELECTRICAL ENERGY
=Z forthwith comply with such pmvisinns or this permit snail W deemed conked.
?O CONSTRUCTION LENDING AGENCY 502 — FINAL PLUMBING ENERGY
Iher by which
that there isaed(See 097, gency lnr the perfurmanccof 503 - FINAL MECHANICAL ENERGY
3'
the work fur whim anis permit is issued(Sec.l09],Co.Civ.CJ
i p Landeri"""° 504 - FINAL BUILDING ENERGY
]z Lenders Address 505 - FINAL ELECTRICAL
J O 1 certify Nall have read the application and state that Lc intoe information is 506 - GAS TEST
y coa
nclagemro
emply with all cityy andand ctumy oNinances and into laws relalingm
=U building construction,and hereby authorimrcpmsentadmsOfLos City toenter wixt he — FI&aEAL
W above-mentioned Pmperly for inspection purposes.
(We)agree to case,indemnify and kith harmless the City of rue gmnino against O — F I
Tq liebilili(We)grento c"su indexponsend ken meymany sson,Cacaneupertitstid City
Z in consequence of the griming of this permit,APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON-POINT Issued by: 5 Date
SOU CE RE LATIONS,
t Re-roofs
awfc Of icamlContracmr Dec -
HAZARDOUS MA RIALS DISCLOSURE Type of Roof
Will the applicant of home Wilding occupant store or handle haiwitous material
as defined by the Cupertino Municipal Core,Chapter 9.13,and the Health and safmy
'Sc y. �Nu
zss3z(a)?
❑Yn All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant Or future building Occupant use a If a roof is installed without first obtaining an inspection,I agree to remove
cn.IPP 6 p a Air Qu of devices whim g
Dw M1avardnus air contaminants ss defined by tW Bay Area Air Quality Managcmcnl all new materials for inspection.
Disvin?
❑Yea 0�Jfm
I have read the hamohous materials requirements under Chapmr6.95 of the Califno-
nia Hcahh S Safety COM.Section 35X15.35533 and 35534.1 understand thio iHW Wilding
Mas not-..ally hoe a mnao.thio it to my espomibilo notify the occupant of Lc
odatjrgp xwnienmuaWmcpdtf ,irsuanee"facefdrea r cupamy. Signature of Applicant Date
U
owner tr amthoaxcd agent Dale All roof coverings to be Class "B" or better