02100137 (2) CITY OF CUPEW11NO � 'n,
BUILDING DIVISION PERMIT ONTRACTOR INFORMATION.
.e ' sC Scam"
BUI D !7,Q DEsPARKVIEW CT PERMITNO2100137
VE0)i SA ABAYNEH APPLICATIPOSNBi"Tj,2002
PHONE: SANITARY NO,/ CONTROL NO.
ARCHUTCT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
L
foo LICENSED CONTRACTOR'S DECLARATION
P 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencingADD 280 SQ. FT.Job Description
N�6r with Section 7am)of Division Sof the Bmincaeand Professions Codeand my licerseis
a. in of l have and effect.
Z p License Class Lic.a
CSF-❑ Dare Commour,
CI'
=£—£� ARCIIITESDECLARATION L
sSy K I understand my plans shall be used as public tmords
��o JUL 2 91003
u ;
U. Licensed Pmfe.whel
OW NF.RBUILDER DECLARATION
to I hereby affirm that 1 am exempt from the Commctnr's License Law for the $31500
n i C O I I owing reason.Section 7131.5,Business and Professions Code'.Any city memory
X$ which requires a permit In construct.alter,Improve,demolish,or repair any struchum
prion,,its romance.also requires the applicant for such permiun life aligned statement
�Z< That he is licensed pursuant with,provisions ofthe Contractors License Laoschapter9 3Sg69t7l0dd5A@a at100
ec heommencingwidnSection 70kB rf Divtmon3 ofthe Businessand Professions Cedc)m
— that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.3 by any applicant for a permit subjects use applicant to a civil Penalty of
not Occupancy
not more Than fva hundred della.(imn). 102 — PIERS
-LuAp y Type
El I,u owner of the property,or my employees with wages as their sole compensation,
will do the work,and On swcturt is not intended or offered for sale(Sec.7041.Business
and Professions Code:The Con racmrs License Law does not apply to an owner of 104 - REBAR Required Inspections
Property who builds or improves Braman,and who dons such work himself or through his
hwn employees,provided that such Improvements are not intended or offered for sale.If, 105 — ANCHOR BOLTS
owever,the building or improvement is sold within one year of completion,the owner. lO6 — SEWER & WATER
builder will have the burden of poising Nat W did not build or improve for purpose of
sale')' 202 - UNDERFLOOR PLUMBING
C,as owner of the property,am exclusively contracting with licensed contractors to 203 - UNDERFLOOR MECHANICAL
I
overt the project(Sec.7MG.Business and Profesti,,ns Code:)The Contractor's Li.
arse low docs not apply lm an mvties of property who Wild,Or improves dressers,and 204 - UNDERFLOOR FRAME
who contracts for nn
such projects with a cmamorfs)licensed Forward o the convectors
License Law. 205 — UNDERFLOOR INSULATION
❑lam exert plunde Sec. 6&PCf nhisr on 301 - ROUGH PLUMBING
0 302 - TUB & OR SHOWER
WORKER'S COMP SATION DECLAP.�.ifON 303 - ROUGH MECHANICAL
and
maintain
ai under p,nalty of ofConmreoftheinsure ing declarations: 304 — ROUGH ELECTRICAL
�Ihares and will for
neCertificate of QemaenlmCode.for farerformace of ft
ution,u provided for by Satin,,37118 of the Itbor Ctge.for rhe pcAurmaae of Nc 305 - FRAME
work for which this permit is issued. 306 — HOLDOWNS
❑1 have and will maintain Worker's Compensation Insurance,as inquired by Section 307 - INSULATION
3701 of the Labor Code,for th,arfonni n.of the work for which this permit is issu,d.
My Worker's Compensation Immarice carrier and Put icy number ase: 308 — SHEETROCK
Coombe: Policy No.: 309 - EXTERIOR LATH
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 310 - INTERIOR LATH
Go resection madmnhecompletedifdtepemritisforrmc hundred dollars(5100 311 - SCRATCH COAT
or lC3s.) 313 - ROOF NAIL
1 amity that in the pe for nc,Of thew ik for hick this Permit is issued.)shall not 5 01 - FINAL ELECTRICAL ENERGY
employ any Pers 'n an nrcrstut � 5ybjellOtbc Workcri Compensation
Laws of cart D, r O 502 - FINAL PLUMBING ENERGY
nppbc�gyynnrrt
NTJAI�l fl,rn kirr6r l(is Ccmilica¢nf Excmptinn,you shoulJ 503 - FINAL MECHANICAL ENERGY
I ueWmkeraCompensationprovisioneoftheLaborCode,youmust504 - FINAL BUILDING ENERGY
OO lonhwuh cth such provisions Or this permit shall Mdeemed revoked.
z 505 - FINAL ELECTRICAL
CONSTRUCTION LENDING AGENCY
[r lhembyaOirmBeat there isaconstruction lending agencyIt"the performanceof 506 - GAS TEST
a > Ibework far which this Permit isissued fSce.304l.CMC.7
lenders Name 507 - FINAL PLUMBING
fill
D z Lender's Address 508 - FINAL MECHANICAL
U O I comity Nat 1 have read this application and mute that the&hove information is 509 — FINAL GRADE
4F j..0 correct,l agree to comply with all city and county ordinances andstate laws rclalingu, 5 FINAL PLANNING
O building concoction,and hereby authorim representatives of this city to enter upon the
aMworeentionedpropertyfor inspection a les.
>" 1 (We)agree meav,indemnity and keep harmless the City of Cupertino against
14 - FIN BLIC W RKS
FIn liabilities.judgments,costs and expenses which may in any way accrue against said City
V z APPI IC c oNDan ERrSTA STAND WILL COMPLY WITH ALL NON-POINT Issued by: Dale I
SO CE TIONS.
e"Julµ Re-roofs
autres fA u Date
AZARDOUS MATE ALS DISCLOSURE Type of Roof
Will the p cant nr fuwre bud ' acupamsmro DISCLOSURE.
hasamais material
as defined by Ne ra Monte Code,Chapter 912,and the Health and safety
de,s0Yes zsmzan No - All roofs shall be inspected prior to any roofing material being installed.
Will Be,applicant or[Ulu riding traupam use eyuipmcm or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hemrdnus aircon.min as derncd by the Bay Arca Air Quality Management all new materials for inspection.
District'/
❑Yes No
nalrldLha ad thade'S,n,n,25.riulsm33.d 55 under Chapled tifthe CaldRng s
doeson,cau Ita he.are liim.mon)5,255and 25534.1 undcrsl:m to he'art of re,
fires nmyyyuuucu t hove u. nt.thin it is my responslbllhyy to nndf IM src Ipant of the
inyuir mush m Tion Issuance etre CcmY'am 'cups c.
It Signature of Applicant Date
owner„r nnnv agent Date All roof coverings to be Class "B” or better
J