03090152 (2)CITY OF CUPEwrINO
BUILDING DIVISION - PERMIT
%CONTRACTOR INF0RMATI0N
>a�Y3nT 80*.�' ?iii+tee `i�Luv. ix'Yeli�'
BUILDING ADDRESS:
PERMIT NO03090152 3090152
OW NER'S NAME:
`17FRnNT(A TAM
PERMIT ISSUE DATE
9/2 ni
NE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLOC ELECT PLUMB MECH
C� 0
LICENSED CONnRSDECLARATION
I
lob Description
underder provisions of Chapter 9 (commencing
I hereby affirm that am litteredd mi
P
With Scniof Division ]of theBminess and Profcuion. Code, and .1 license is
in full fo la andndeffect. effect.
(once
Licenx Clam Lica
DEMO (E) POOL
Data Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
SEP 2 4 2003
Licensed Pmfcmuoml
OWNER -BUILDER DECLARATION
1 hereby affirm that Iam exempt from the Contractor's License Law for the
BUILDING
following mason. (Section 711]1.5, Business and Pmfessiom Code: Any city or county
which ox irra a Permit m eonammi. alma improve, demalLvh, or mpair any structure
Prior us its issuance, also requimvhe applicant forsuch Permit to file a signed statement
that he is licensed pursuant to the pmvisionsofthe Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencingwith Section 7880) of Division ] of the Business and Promasions Code) or
Inn he is exempt therefrom and the basis for the alleged exemption. Any violation of
31635004.00
_ _ .. -.. APN Number
Occupancy C_.
P y T'P
Section 7031.5 by any applicant fora Permit subjects the applicant to a civil Penalty lir
- _ .._ __ ....
not more man five hundred dollar. (SS00).'
...-
_
❑ 1, as owner of the property, in my employees with wages as their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered r ... In(Sec. RMS, Busi neo—
and Professions Cade: The Contractor. Lin" , law does nut apply to an owner of
e Q ns p
property who builds or improves demon. and whodoes such work himselfor through his
own employers, provided that such improvements me not intended or offered for sale. It.
hawewq Ne building or improvement is sold within one year of completion, the owner
builder will have the human of proving that he did not Wild or improve for purpose of
sal .).
1, as owner of Ne property, am exclusively contracting with licensed convectors to
cc over the reject (Sec. 700x, Business and ofmiam Cade:) The Ct nuaceiri U.
cerise Lawd not apply to an owner of prop y ho builds air improves menton, and
woo conuac for such prgeeb with aeontrxm li nxd purauanuo the Contractor's
License Law.
❑lam eaemt oder See ,B&P this r�
17 �n
,
-- ORKER'SCOMP NSATIONDECLJR TION
I hereby affirm under Penalty of perjury one of the following declarations:
I have and will maintain a Certificate of C4.eal to relf-inxm for Worker's Compere
ration,. provided for by Section 3700 of the labor Code, for me performance of the
work for which this permit is issued.
-
❑ 1 have and will maintain Workers Compensation Insurance, es required by Section
37W of the labor Code. for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number sm:
Cartier: Policy Ne.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section tetrad nm hecomplemd Rate Permit a fm enc hundred dollars n If1()
lir less.)
1 cenify that in the performance, of the work for which this Permit u issued, I shell not
employ any person in any manner sat as w become subject o the Workeri Compammilon
Law. .(California Dam
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation previsions of the Labor Cade, you must
forthwith comply with such provisions or this Permit shall be deemed minima.
,
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agenry, for 1M performance of
the work for which this permit Is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Add.,
I cenify Ino I have read this application and SUM that the above information is
correct. 1 agree to comply with all city and county ordinances and same laws relating to
building Conswction, and hereby aumorix representatives of this city to enter upon the
above-mentioned property for inspection purposes..
(We,) agree eco save, indemnify and keep harmless the City of Cupcnino.g111.1
liabilities,] gmcnu,c.a.nd.pcnwhich may in any way atenagainst mid City
in eonuq. cc of dam ming w x of this
/
gm permit.
APPLICA OERSTANDS AND WILL PLY WITH AP INT
Issued by: Date
SOURCE R LATIONB.
Re -roofs
Si azure of p m nV ser mr 1 1 Data
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupmutom or handle haramons material
u defined by me Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
code. Ormexss]2(a)?
All roofs shall be inspected to any roofing material being installed.
j$N.
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building Occupant tau equipment or devices which
,t hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
Ohm?
❑Yes '�QJo
Ir. a mad th,hvaNnd/sm .Ismyvimmcnu un der Chapter 6.95 of the Califon
ria Health Samlycode,Seetom25w ]]and 255]0.1um MdmWthmifdCWilding
does not c n y have a mnanL Not it' y responsibility m no upset of the
Bq men is must N met priors issuance or. Centric= c c
Signature of Applicant Date
o 3
All roof coverings to be Class "B" or better
bwnmr
ar ant rnima .sem Date
r
J�•
(WIT
CUPERTINO
CITY OF CUPERTINO
DEMO
PERMIT APPLICATION FORM
b3o76/s q�
APN #
/S"J)
BUILIDNG
Date: �} / % /03
Buildin Address
BSEISMICOM
Own is N :I
BUILIDNG
—e
Phone #: /�D
Contractor:
/ BSEISMICRE
Seismic Residential
BUILIDNG
License #:
Contact:
BPLANCHK
Phone #:
Applicant/Contractor:
ildipg Permit Info:
(Bldg,/
Elect,—>
(Plumberech
b5
'Description:
Residential:
Ce }
Commercial:
Sq.Ft. Floor Area:
$/Sq.Ft.:
Architect/Engineer:
ValuatiKnlej
Type of Construction:
Occupancy Gra p:
rA
Qty. if
Anol able i Fee ID
Fee Descrintion
Fee Groun
f BPERMFEE
Bldg Permit Fees
BUILIDNG
BSEISMICOM
Seismic Commercial
BUILIDNG
—e
/ BSEISMICRE
Seismic Residential
BUILIDNG
BPLANCHK
Plan Check Fee
BUILIDNG
BUSLIC
Business License
BUILIDNG