03030122 (4) CITY OF CUPERTINO ft
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BUILDING DIVISION PERMITCONTRACTU�R IN1ORIA7IQ_N
BUILDING ADDRESS: - PERMIT NO.
7Arr RD
OWNER'S NAME: PI7U4IT 159 A
SANffARYN OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LOO LICENSED CONTRACTORS DECLARATION lob Descri tion
ii�� 1 hereby affirm that I am licensed under provisions of Chapter 9(Commencing p t� �p p p tt�
n< with Section 7")of Dolton 3ofthe Business and PmfcWnns Code.md my licerue is - tI—�®�+1�A.2a.1I,�i®
In full force and effect. F ®FSI]
jRjE License Class Lie.« KITCHEN REMODEL
Dale Contractor
ARCHITECTS DECLARATION MAY' l 2 2003
1 understand my plms shall he used u public mcords
G Licensed Professional fROWNER-BUILDER DECLARATION BUILDING
q9 I hemhy arNthe
e at 1 em exempt form Contractorla
Contractors License w for IM
+opo following memn.(Sadun 70313,Busionsand Profesdoe Code:Anydty.,county
$ which mqubm a Permit to constorm,alar,Improve,demolish,or repair any structure
prior to iss issuance.9.require the applicant for such permit to rile a signed statement
< that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 Sq.Ft.Floor Area �{Tsr7lon
zG (commencing with Section 7000).(Division 3 of the Business and Professions Code)ur ""'
3 that he Is exempt therefrom and the bub for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subject,the applicant to a civil penalty or 3�pJ i��0�r 0 0 - Occupancy Type
not more than five hundred dollars(3513).
I,uowner of tie ProPcitY•.r my employeu with wapeau0eir sole compenPasian,
will do the,work and theswnue isnot intended or offered for.1.(Sec.70th,Business 101 - FOUND
and professions Code:The Conlmnera acme,law does not apply In an comer or AiEcjd d Inspections .
property who builds orimnows lhere.n.mel who doessuchwmkhimselfor through his 102 - PIERS
own employes,provided thatsuch improvements ale not intended moRmred fmsale.If. 103 — iIFER
however.the building or improvement Is sold within one year of complethm,the owner.
builder will have the burden of proving that M did not build or improve for purpose of 104 - REBAR
�'j4,ens owner of Ne property.am exclusively contracting with licensed contractor,to 105.. — ANCHOR BOLTS
construct the project(Sec.7004,Buslnm and Professions Cade:)The Contractor's LI- 106 - SEWER & WATER
can=law dees not apply town owner of property who builds or improves themon,and, 'ZO2 — UNDERFLOOR PLUMBING
who contracts for such projects with a conimtoKto N
s)licensed pursuant e Contractor'.
Lkann U. 203 - - UNDERFLOOR MECHANICAL
❑lam exempt under Sm. MasonB&PCfor this rtan
�' oa )
° t,�2�S RCN 204' - UNDERFLOOR FRAME
� R'SCOMPENSATON-0ECLARAD 205 - UNDERFLOOR INSULATION..
Ihembyaffmn under penally of perjury ore of the following declarations: 301 — ROUGH PLUMBING
❑I have and will maintain a Comments ofconscm to self-Insum for Wortrra Compere 302 — TUB & OR SHOWER -
smion,u prodded for by section 3700 of the Labor code.for Ire performance of the - 3 03 - ROUGH MECHANICAL - -
workforwhichthispermitisissued
❑I have and will maintain Wmtrr'a Compensation Insurance,as requhed by Section - 3 04 — ROUGH ELECTRICAL -
37MoftheLabor Code,for the performance of the work for which this permit Is lured. 305 FRAME
My Workers Compensation Insurance artier and Policy number sec: -
CeMer. Policy Na: 306 - HOLDOWNS
CERTIFICATE OF EXEMPTION FROM WORKERS' 307 INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK '
(This auction need not w completed if the remit is for one hundred dollars 309 - EXTERIOR LATH
nr less.) '
I
certify Net in Ne perfmmanec of the work for which NB permit b Issued,I shell not 31 0` — INTERIOR 'LATII -
i.aw the,rfc.hfmo t 'yma�crm. C enbjeelmhc or riC.mpenntlon 311 =' SCRATCH COAT
-
2nWe
App ca - 313 . _ ROOF NAIL '
N a or mating this Certificate orEx,mpllon.you should 501 FINAL ELECTRICAL ENERGY
tom a subject to the Worker,Compensation Provisions of the labor Cade,you muss
,JO fonhwiNeomplywithsuehpr.wmsmthbpermiuhallbcdecmedmvotrd. 502 . — FINAL PLUMBING ENERGY .
z0 CONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL ENERGY
.> kforwh.fhtmthatthemlaamd(S..3 l,Civ.C.) fonwprfmman nr 504 -• FINAL BUILDING ENERGY
R, � Iw work for which this permit is issued(3r,.]091,Civ.CJ
W M Landcr'eNama 505. - FINAL ELECTRICAL
a. LemaeraAddmPa
GZ 506:- - GAS TEST - ' - '
U 0 1 cenlfy Nu 1 have read this application and.tate the,the above Information la
11. F erect.I agree to comply with all city and county ordinances and eine laws relating to 507 - FINAL PLUMBING' 1(//(�/�/J�/!
buildingendonection,and rot by imanthun purposes
elivciofNbdry to enterupon silo V
OU above-memton,dpmp end heriupCthodheofms. '- FIWNWG AL
(We)egme to rave,indemnify and tree harmless the City of Cupertino agdut 0 9 FI
fag
liabilities judgments,casts and expense which may in any ray memo against Paid City
C)Z in consequence of Ne granting of this permit. SAPPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:5Date
SOU E G LATIONS. I 2tiry, Q�Hzoo
Re-roofs
SISrumneVrAfilpficattoCmutratim
H
HAZARDOUS MATERIALS DISCLOSURE Dam. Type,of Roof
Will Ute ipplicanl or(mum building occupmet.m urhandic ham'sous mammal
as defined by the CuperimK.N.1milding;
pal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(e)?
❑Yrs
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant occupant use equipment or dcviroa which If a roof is installed without first obtaining an inspection,I agree to remove
IhauNnus air comamanu Ne
inss defend by Bay Arta Air Quality Management all new materials for inspection.
Dix ICL?
❑Yes
In,-mW Ne huardous materials requirements under Chapter 6.95 of the Califon
m.Hoafh A Safely Code,Sections 25505.25533 and 25534.1 understand dual lithe wilding -
dues not currently hoe a Ionam.that II is my responsibilityndfy the occupant M the
roquimmenisw Ic upt be met Mor to issuance or a ccohr!oto wanew �p Signature of Applicant Date
o . .ed Agent ' Dow W (7� All roof coverings to be Class"B"or better