03040138 (2) CITY OF CUPERTINO '• led -'� ° " ' ' ` s
BUILDING DIVISION PERMIT CON'TRACfiU12,TNFRMAION
BPt9131g2DDffENEY CREEK PL "am"°03040138
Ir•S IRMY B AND HOWARD F PERMTr 1$IfBOq]'!t 0/2 0 0 3
ONE: SANITARY NO,
/ 3 CONTROL NO.
ARCHITEC 0Eb1GINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�oo LICENSED CONTRACTOR'S DECLARATION lb Description
I herchy a(Rnn that I am licensed oM o
under pmviuof Chapter 9(Commencing P
with Section] f Division 3 of the Bond!"Professtoa Code,and my It...is
I.full forte on T
Lie.na I Lle.g f `a TERMITE REPAIR
�1- D ARCHITECTSD RATION CONTRACTOR: ANTIQUE TERMITE &�•,��LED
'� understand my plena shall W used as public retards '
76
3 a Licensed Pmfessitnal
Oat I am exempt
from
DECLARATION MAY 0 7 2003
I btraby.(Item that 11. emmpt from the Cssiom o License Law for eM
p O following rtnsoa(Section]1131.3,Business and Improve.
de au Cole:Any city a county
$ which rcyusu¢permit I.re cares Wo alter.Improve,h permit
sere I sig anyawmam
F Z<
print to its issuance.pursuant alsin We pmvishms o far sucr We conlosrmie m Fite a signed(chlcmcm
FF O thohcincing �Jction7 We 3oftheBuanessacines ntxuclaw(Chdia)orapter 9 Sq.Ft. Floor Area
et Fps (eat he Is(commencingwith herfrom and basisofrthe alleged
exemption.Ans ny
or
3�
that he la exempt therefrom and Ne beau!ser the a1legca exemption.Any vlolatibn of
Section 7031.3 by any applicant for a permit ubjects the applicant to a civil penalty of APN Number Occupancy Type
nut more Nan Tive hundred dollars(5500).
01.as owner of the property,or my employees with wages as their sole compensation, 34248034 . 00
will do the work,and We swcmre is not intended or offered for sale(Sec.7044,Busineu Ret-�yw�ired Inspections
and ons m ProfessiCode:The Comracures License raw does am apply an owner of 10 1 — FOUNDARe VN
property who huilda or impmws themon.and who dues such work himsel!or through his
own employeesprovided thin..,imprnrcments sm.,Intended croffered Wale.If. 102 — PIERS
howevar,We budding or improvement is sold within ore year of completion,the owner•
builder will have the burden of proving Nat M did not build or improve for purpose of 103 — UFER
ale')' 104 - REBAR
O I.u amor of the property,am exclusively contracting with licensed contractors a 105 — ANCHOR BOLTS,
Construct We project(Sec.7W.Business and Professions Code:)The ConuacmM1 Li.
«tie Law dose not apply It an..a,of property who Wilda or improves therton,and 106 - SEWER & WATER
who contractsfor such projects with a conVactor(s)licensed pursuant to the Cumnmor's
Lle.tlalaw. 202 - UNDERFLOOR PLUMBING
❑l am exempt under See ,B&PCfm this moon 203 - UNDERFLOOR MECHANICAL
°r Data 204 - UNDERFLOOR FRAME
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations: 205 — UNDERFLOOR INSULATION
❑?haw and will maintain a cminicam or Consent o self-insure rot Worker's Chopper. 301 — ROUGH PLUMBING
cation,as provided for by Section 3700 of the Labor Cade,for the performance of the 302 - TUB & OR SHOWER
work for which this Permit is Issued. 303 - ROUGH MECHANICAL
❑1 have and will maintain Worker's Compensation Insurance,as no imd by Section
3700 of the labor Code,for the perlormmce of the work for which this permit is issued. 304 — ROUGH ELECTRICAL
My Wor r' Ca pens ton In nam artier and Pul' nutrLbS�ia�ro: _�n 3 05 — FRAME
c' Paliryl [� vG /4 306 - HOEDOWNS
CER7Ia .OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 307 - INSULATION
(Thi,,section need not W complete)lithe permit Is rorone,hundrcddollars($1M) 308 - SHEETROCK
orlca) 309 - EXTERIOR LATH
ecertify that ethe manco of the work hot which this permit is issued.I shall nm 310 - INTERIOR LATH
employ any person inany manm become subject to eheworkcri Comns
peation '
Laws of California.Data 311 - SCRATCH COAT
Applicme
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should 313 - ROOF NAIL
become subject to We worker's Cumpewtion provisions of tilt Labor Code,you must
OZ. forthwith comply with men provisions or this permit shall bodeemed revoked. , 501 — FINAL ELECTRICAL ENERGY
'ZO CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
'F '4—' IhemhyatfmnthatthereisaContructionlendingagencyfortheperformanceof 503 - FINAL MECHANICAL ENERGY
Ix E thework for which this permit isissued(Stt.3097,Civ.C.)
Ila Q Lender's Name 504 - FINAL BUILDING ENERGY
DZ <naeraAeaes 505 - FINAL ELECTRICAL
U 0 1 certify that 1 have read this application and slate that the above information is 506 - GAS TEST
^' coma I agree to comply with all city and county ordinances and sate laws relating to
building construction,and hereby autharlee representatives ofthis city to enter upon the FINA PLUMBI G
>4 ahovamentianed properly for inspection purposes. Q8 FIN L
(We)agree to ave,indemnify and keep harmleu the City of Cupertino against
F' N liabilities,judgments,costs and espenw which may in any my acrnc against said City C,
C.j 7 In consequence of the granting of this permit.
F7 APPLICANT DERSTANDS AND WILL COMKX WITH ALL NON-POINT Issued by NG Date
S URCER LATIONS. r �f b114 —
Re-roofs
PUJ
Signature of Applican on mr ' Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will We applicant or future building occupant some or handle nuessmou material
as&Rncd by the CuNnim Municipal Cade.Chapter 9.12.arta the Health and Safety
PC.Scent.25532(e)?
❑ All roofs shall be inspected prior to any roofing material being installed.
Yes o
Will the applf=mt Co rutum Wilding occupant use equipment or dcvicu which If a roof is installed without first obtaining an inspection,I agree to remove
emit harardou air contaminants as)alined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes Nu
Ihawmal Lh.hasardt smamrlatsrequimmenuun&rChapterG95oflheCalifor-
niaHulth&safely Coda Sccdau23505,25533uWZ5534.1u tkrpana thulfthc Wilding
Joo��((yyI currently II a tenanti that it is my rcsponsihility m 111 the 'Pant of the
byeB4mcnuw m.,u�n.7yWmet Iirmnten Coraceific- may. Signature of Applicant Date
Owner ur,uthnriaca.gcnt ((ffY'Yll r � All roof coverings to be Class"B"or better