03090171 (3) _777
CITY OF CUPERTINO -"� r^"� '
77
BUILDING DIVISION PERMIT toTRACTQR INFORMATION ',_
BUILDING ADDRESS: PERMITNO.
MOSSOTTI VICTOR G ET AL 03090171
eR'S NAME: PERMIT ISSUE DATE
1MOSSCITT Im-Top r—, ET Al
PHONE:
SANITARY Ni 9112 3112 ONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
�Op LICENSED CONTRACTOR'S DECLARATION
Id C ith SI hereby affirm that 1 Am licensed under ppmebinns of Chapter 9(commencing Job Description
U with Section of Division 3 of the Business and Professions Code,and my license is
n in full force and effect.
;M= Lieenmclax Lie,» KITCHEN REMODEL
o Dam TSDECL FINAl,.P�D
S ARCHITECTS DECLARATION
J a< 1 understand my plans shall he used as public records
>yU
=o„
Licensed Professional MAY 2 4 2004
3 OWNER BUILDER DECLARATION
Ca F I hcrcby affirm that 11. exempt from the Contractor's C License Lew for the
C20 following uiresreason.Permit
it]191.5,Business antl Professions Code:Any city ns county
which to issu n permit re restconstruct,almn improve,demolish, fie asig any structure
prior aria issuance.also requires the applicant for permit file axigned statement
< (bathe islicensedpursuamloure pmvisiansofthe Contratmr License Law(Chepmr9 ` Sq.Ft. Floor Area Valuation
'Fct (commencing with Section 7")of Division 3 of the Business and Professions Coro)or
�,�$ '14240022 0
Nat he is exempt Nemfore and Ne basis for the Alleged exemption.Any viNal(on of
Section 7031.5 by Any applicant for a permit ubjectsthe applicanuo a civil penalty of APN Number Occupancy Type
not marc than Eve hundred dollars($500).
❑1,as owner of the property,or my employees with wages a their sole compensation,
will do the work,and the structure is not intendedoc.frecd far sale(Sec.]044,Business 101 - FOUNDP.40id Inspections
and Professions Cade:The Contractor's License Law dors not apply to an owner of
property who builds orieproves Noreen,And who doessuch work himself or through his 102 - PIERS
ownemployces,provided thatsuch improvements=riot intended proffered forsale.If. 103 — UFER
however,the building or improvement is sold within can year of completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of 104 - REBAR
salt.).
I,as owner of the property,am exclusively contracting with licensed Contractors to 105 - ANCHOR BOLTS
comweLLhe Project(Sec.P)44,Business and Professions Code:)The Convector's Li- 106 — SEWER & WATER
cense law does not apply to an Owner of property who builds or improves thereon,antl 202 - UNDERFLOOR PLUMBING
who contracts for such projects with a contracmro)licensed pursuant o Ne Contractor's
( cad.Law. 203 -
.B&c fr UNDERFLOOR MECHANICAL
1 asn exemp a Sec. h
204 - UNDERFLOOR FRAME
O KE ' COM I oN L`aR ION 2is rcss n 205 - UNDERFLOOR INSULATION
1 hereby affirm under penalty of perjury one of the following declarations: 301 — ROUGH PLUMBING
73011
have and will maintain a Condition of Consent selGinsurc mrworkers Compere 302 — TUB & OR SHOWER
n,a provided for by Section 3]00 of the labor Code,for the performance of the 303 - ROUGH- MECHANICAL
for which Nis permit is iapcd.
have and will maintain Worker's Compensation Insurance,as required by Section 304 — ROUGH ELECTRICAL
of the Labor Code,for the pedermanec of the work for which this permit is issued. 305 — FRAME
Worker's Compensation Insurance carrier and Policy number ate: 306 — HOLDOWNS
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 - S+HEETROC.vK .
(Thlasection need not he completed if the permit is franc hundred dollars($100) 309 — EXTERIOR LATH
or less.)
I certify Nat in the performance of to work for which this permit is issued,l shall not 310 INTERIOR LATH
employ any person in any manner so a m become subject to the Workers''Compensation 311 - SCRATCH COAT
Laws pant f California,Data
Applic - 313 - ROOF NAIL
NOTICE TO APPLICANT.Worer ComNn5mmm rCcnins Of ofE Labor Codeyou,
muld
st 501 - FINAL ELECTRICAL ENERGY
become subject Ip the Workers Compensation provisions Of IhC labor Cndc,you must
,Z forthwith comply with such provisions or this permit shall he deemed invoked. 502 — FINAL PLUMBING ENERGY
zo CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
H"' Ihereby affirm that there isaconswctionlending agency for the perfovnenceof 504 - FINAL BUILDING ENERGY
E4
> ate work for which this permit is issued(Sec.309],Co.C.)
W q Londer'a Name 505 - FINAL ELECTRICAL
Lenders Address
DZ506 - GAS TEST C�
U Q i certify that I have read this application and slam that the above information is
fL cprrem.l agree to comply with all city and county ordinances and-sere laws relating IV 507 - FINAL PLUMBING
building construction,and hereby addictive representaims of Nis city to enter upon the
�C.) above-mentioned property for inspection purposes. JINMEC CAL
FG (Wc)agree m save,indemnify and keep harmless the City of Cupcnino against O 9
N liabilities,judgmenks.costs and expenses which may in any wayaccmeagamst said Ciry G
V peonsintione^' APPLICANTeUfshERSTANDSIAND WILL COMPLY WITH ALL NON-POINT Issued b 5 NG Date
C WORKS
S R ATIONS. y'S
Re-roofs
Sign arc of Arcant/Comfacmrm
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant smm r handle hazed res material
defined by the Cupenina Municipal,Code,Chapter 9.12,antl the Health and Safety
ic,Section 25532(a)?
El You RV All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants a defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes "Wo
I have toad the hereabouts materials reyuitements under Chapter 6.95 of the Cali far.
nia Health&Safety Cuda Secuem 25505.25533 and25534.1 undemwd Nm if the building
does of currend have a tenant,that it is my responsibility to nodl'y the occupant of the
content ir, —sseh mustMmtpndorwissumecofe imof Occupytcy�/� Si gnature of Applicant Date
Owner Vradlhdrncd agent 4=f .y2a�Jf�/FgD'r All roof coverings to be Class"B" or better