02100144 (2) C[TV OF CUPERTINO
BUILDING DIVISION PEATCONTRACTOWINFORTION;"..
.sem %r 1_T",
RDI Ql1c6fgl81sFLINTSHIRE ST THE REMODELING PROJECT PERMITN(02100144
ZIGNAfI'OWICZ JOSEPH B AND ELE 0724 BERRY AVE APPLIcATB11D fp%2002
PHONE: (650) 969-2555 SANITARY NO, CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELCCT PLUMB MECII
12OO LICENSED CONTRACTOR'S DECLARATION
C U F I hereby al firm that I am licensed under provisions of Chapter 9(commencing Lr
�« with5cctinn]aNrynfDivisinn3olthcBusinessunJPndcssiomCode,wmmyliccnscta REVISION— —IN ��� ONLY
in full Time and effect. (ORIGINAL #02060019, REVISION 402080108)
t- W
z o'q 2 License ClassLic.N
Fy W Date Cmaramor NO NEW PERMIT ISSUED
P� ARCHITECTS DECLARATION
I understand my plans shall Be used as public rtenrdz
od \
m 3 a F Licensed Prnlcssinml /
=y0� OWNER BUILDER DECLARATION
Ka x 1 hereby w rifle that 1 am exempt from the Contractor's License Law lin the s
i m0 following reason.(Secimn 70315.Business and Pml'esvions Code:Any city or county \`C
�i which rcquircs a Permit m construct,alter,improve,demolish,or repair any structure
priori its issuance,also requires the applicant for such Permit o rile aeigncd statement
IzaG that he is licensed pursuant to the provisions of the Contractor%License Law(Chapter 9 Sq. Ft. Floor Area $30Wation
tel- (commencing with Section]IXXB of Division of the Business and Professions Code)or
y
That he is exempt Ihemfrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penally of
not marc than five hundred dollars(55x0. e Occupancy Type
I,as Owner of the pfopcny,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.700.4,Business 18i Febiiil
and Professions Code:The Comeactors License law docs not apply to an owrrtr of 102 - P I ERS egwred Inspections
pmpeny who builds or improves thereon,and who does such work himself or through his
own employees.provided thaumch improvements are not intended or offered for sale.If, 103 - UFER
however.the building or improvement is sold within one year of completion.the owner- lO4 - REBAR
builder will ban the burden of proving that he did not build or improve for purpose of
W.) 105 105 - ANCHOR BOLTS
❑I,as Owner of the property,am exclusively contracting with licensed contractors to 10 6 - SEWER & WATER
construct be project(Sec.](44,Business and Professions Code:)The Contractor's Li-
censelawdoesnorapplytoanownerofpropertywhobuildsorimproveslheron.and 202 - UNDERFLOOR PLUMBING
who contracts for such projects with a contractor(s)licensed pursuant to The Conuanor'a
Licenseww. 203 — UNDERFLOOR MECHANICAL
I am exempt under Sec. ,B A,P C for this reason 204 - UNDERFLOOR FRAME
.or Dat 205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATIONDECLARATION 301 - ROUGH PLUMBING
I hereby follow under penally of perjury one of the following deelaraions: 302 — TUB H OR SHOWER
ThansprdwedforbySectin3701Caut oftheLabrCodtel .foremrerformacern iroofthe 303 — ROUGH MECHANICAL
cation,as provided for by Section J]INI of the Tabor Code.far the performance seri the
work for which this .it isbsued. 304 - ROUGH ELECTRICAL
❑ 1 have and will maintain Worker's Compensation Insurance,as rtquired by Section 3 0 5 — FRAME
3700m the labor Cask,fill Ne performance of the work fur which this permit e,issued.
MyWr¢ers Compenamim Insurance carrier and Policy number we 306 — HOLDOWNS
Cnrien Policy No.: 307 - INSULATION
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 308 — SHEETROCK
crhi.,archo.need not The completed if the perm it is for one hundred dollars(S 100) 309 - EXTERIOR LATH
I'r IeSL) 310 — INTERIOR LATH
employ
my erthe n any
er T the work for which this Form itisisucd,lshallnm 311 — SCRATCH COAT
Laws o any person in any manner so M at become subject to the Wrrkcri Compensmion
Lawsorcahlbmia.Date 313 — ROOF NAIL
Applicant
NOTICE TO APPLICANT,11.after making this Cenificme at Exemption,you should 501 — FINAL ELECTRICAL ENERGY
become subject to the Worker's Compensation Provisions of the labor Curie,you must
O zforthwith comply with such provisions Orthis Permitshallla,deemed revoked. 502 — FINAL PLUMBING ENERGY
Z o` CONSTRUCTION 503 — FINAL MECHANICAL ENERGY
F N-' I hereby affirm that the re is a construction lending agency for the Performance of 504 — FINAL BUILDING ENERGY
C > be work for whichthis form itisissued(see.3097.Cie.C.)
Leads,a Name 505 - FINAL ELECTRICAL
a
� z
Lenders 506 - GAS TEST
U O 1 cenify that 1 have read this application and sure that the above information is 507 - FINAL PLUMBING
U. F.
rating to
ccorrect.lags to comply with all city and county ordinances laws re5 FINAL MECHANICAL
V building constriction. ad herebythor
hy turn rtpresenutives of this ciymenterupm the
>iwabove mentioned property for inspcenon purposes. O9 FIN GRADE
(We)agree to save,indemnify and keep harmless the City of Cupertino against
H h Liabilities judgments.costs and expenses which may in any way acme against said City 5 F N N G
V z Aconsequence of the UNDERSTANDS
of this permit l/
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by51 WORKS Dale
SOURCE REGULATIONS.
Signature of AppRe-roofs
l¢anJComracmr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will The applicant or future building occupant sore or handle hmardnus material
dermed by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
At.Soemn 255721x)]
❑Yes 0 N All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future baildingarupantbe,equipment ordevieciwhich If a roof is installed without first obtaining an inspection, I agree to remove
emit hatardous air Contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Diatricil
❑Yes ElNo
I have read the humorous materials reyuiremenm under Chapter 6.95 of the Calif or,
nia l Rally K Sefely Cook,Sccimru 25505.25577 and 255]4.1 undcrsund that ifddc Building
doe t mts moody haa¢nam.that it is my meprnsfbility m mlin occupant loccupant of the
requNo
which mustM met prior to isauemee ofs Ccmrcate of Decuparcy Signature of Applicant Dale
Owner ofautmnimdagent Qa,e All roof coverings to be Class "B"or better