03020045 (3) CITY OF CUPERTINO - ,3 ` �••••••
BUILDINGDIVISION PERMIT CON 4A4
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BUILDING ADDRESS: PERMIT NO.
20305 NORTHGLEN SO 0-102004c;
OWNER'S NAME: APPLICATION SUR DATE
SPRINGER LARRY A 02/12/2003
ONf3: SANITARY NO. CONI'ROLNO.
ARCHITECT/ENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
WOO p LICENSED that
I maCONTRACTOR
under 4 DECLA..mums f Cha,
�Up eherebyaffirmNat1amIfdbaBmunderprovisionsofChapmr9(commencing Job Description
<� with Scninn]mpof Divisionlof NC Rosiness anJ Prufcmiam Calc.end myliccnse is
in mum ea er f. KITCHEN RENOVATION
zolab Liccnsc`I� Li
0z a - ae r Sat+A��N— CONTRACTOR: ACTON CONSTRUCTIOI ALE®
ARCHITELTS DE ALIGN
�o u l unders�ndnderaund my p Pu lie ummas
ed Licensed Professional MAY 0 w 2003
Is, OWNER-BUILDER DECLARATION
co <Y I hereby affirm Thal I am exempt from the Contractor's License Law for the
i r O0 following reason.(Section 7131.5,Business and Professions Codc:Any city or county ��'
W Q� which requires a permit to construct,alter,improve,demolish,or repair any srucwre
prior to its issuance,also"dims the applicant Lor such Permit file a signed naamcnf
XR< that he is lice nwdpumuatntothe provisions oftheContracto;sLicense Law(Chapter 9 Sq. Ft. Floor Area Valuation
ooll'$ (commencing with Section loath of Division 3 of the Business and Professions Code)or $56000
y Nat he is exempt Nemfrom and Ne basis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicurtfor a Permit subjects the applicant to a civil penalty of APN Number Occupancy Type
Out more Nan five hundred dollars OSWO. 3164106O . 00 p y yp
❑1,as owner of the propeny,or my empluyeca with wages m their axle compensation,
will du the work,and the sweum is not intended or offered for sale(Sec.Tom.Business
and Pormadons Code:The Contractor's License Law does not apply to an owner of 101 - FOUNDAfttWd Inspections
propeny who builds or improves onercon.and who does such work himself or through his
own employees.provided that such improvements are not intended or offered for sale.If, 102 — PIERS
however,the building or improvement is sold within one year of completion,the owner.
builder will ban the burden of proving Net he did not build or improve for purpose of 103 - UFER
a") 104 - REBAR
01,as Owner of the progeny,am exclusively contracting with licensed contractors to 105 — ANCHOR BOLTS
construct the project(Sec.7044,Business and Pmfessions Codl The Contractor's Li.
cense Law does not pply In an owner of property who builds or improves thereon,and, 106 — SEWER & WATER
who contracts for such promem with a coplowler(s)licensed pursuant o the Commicror's 202 - UNDERFLOOR PLUMBING
License Law.
❑I am cxcmpt under Sce. .B&P C no thisrcas^n 203 - UNDERFLOOR MECHANICAL
caner Data 204 - UNDERFLOOR FRAME
WORKER'S COMPENSATION DECLARATION 205 UNDERFLOOR INSULATION
1 herehy olTrm under Penalty of penury one of the following declarations:
Fl have and will maintain stCerieceeofConsent oseIf inions for Wurkcr's Compere 301 — ROUGH PLUMBING
sation,as provided for by Section 3700 of the labor,Cade,for the performanw of the 3 02 - TUB & OR SHOWER
work for whichhisp.itisissued, 303 - ROUGH MECHANICAL
❑ 1 have and will maintain Worker's Compensation Insurance,m required by Section 3 04 - ROUGH ELECTRICAL
3701 of the Labor Code,for Ne performance of the work for which this permit is issued.
My Workers Compensation Insuancc cwricram Poli�cy nu[r9/Icor rc}:� 305 - FRAME
c p: SraS� 5..,,aa PolicyNo:_ ILVziD(' 306 - HOLDOWNS
CERTIFICATE OF EXEMPTION COMPENSATION INSUROCLORKF:RS' 307 — INSULATION
(Thissection need nuthecumplead iflhc permit is mrone handed dollars(S10) 308 - SHEETROCK
ml`aa) 309 - EXTERIOR LATH
I certify that in the Performance of the work for which this Permit is issued,1 shall not 310 - INTERIOR LATH
employ any permn in any manner m as to become subject to the Workers'Compenamion
Laws of California.Date 311 - SCRATCH COAT
Applicant
NOTICE TO APPLICANT:IL after making this Cenificam of Exemption,you should 313 - ROOF NAIL
become subject to the Worker's Compensation provisions of the Labor Code,you must
0 Z forthwith comply with such provisions or this Permit shall Pedeemed revoked. 501 — FINAL ELECTRICAL ENERGY
z � CONSTRUCIONLENDINGAGENCV 502 - FINAL PLUMBING ENERGY
F .N. Ihereby armmOut them isacomuuctionlending agency for the performanceof 503 - FINAL MECHANICAL ENERGY
C' the work for which this permit is issued(See.YN7,Co,C.)
w p Iaad,r'sName 504 - FINAL BUILDING ENERGY
5z Lender's Address 505 - FINAL ELECTRICAL
U O 1 certify that 1 have mad this application and suite that the above informuion is 506 - GAS TEST
LL F correct.1 agree to comply with all city and county ordinances and sate laws relating to
0 U building construction,and hereby aulhoficc mpresenlatives of this city to enter upon the 5 1 FINAL PLUMBING
progeny above mentioned for inspection purposes.
�'r C (We)agree to save.indemnify and keep harmless the City of Cupertino against FIN L
tih liabilities,judgmenls,costs and expenses which may in any way.ccme,against said City 508 N
U Z in consequence of the granting of this Permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL IN Issued by51 - NG Date
:A
S EREGU
"I `�-� Re-roofs
Signaarc of Applican✓ pnu.eor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the aPFlicam nr Tutors building wcupam store nr hanJle hassNnus mamrial
m defined by the Cupenino Municipal Code.Chapter 9.12,and the Health and Safety
Code goes 255321a)7 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
cool hasardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑yea Nu
I have read the hvardoux materials mquirementx under Chapter 6.95 of the Cali for.
nits Healon of Safety Codc,Sallons 255115,25533 and 25534,1 undersand dint if the building
does not currently hove a tenant,that it is or,responsibility m nobly c oecupam of We
�` whmhmaat ,mpnmtoissa cenfaCertificammlR ancy. Signature of Applicant Date
( 4 \✓,J All roof coverings to be Class "B" or better
`� Owner or mah.n.d agent Date