02100015 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONT�RACTFOR INFORMATIOW".-
'U'll-10180,DDRAIDBINDELL WY BB CONSTRUCTION PERMIT NT 2100015
it Ii:3Fn`ftHUGO E AND E-PING S 3535 ROSS AVE . STE 105B APPLICATIQf' INt®'21J 2002
IONIi: _40-872 6-6-6 2 6 6 SANITARY NO. 77 CONTROL NO.
ARCHTICr/ENGINCER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u w� LICENS[D CONTRACT'OR'S DECLARATION
F I theicb,raffirroffirt,1 on beenwd ande, mvismm of Cha bf i) enmmencile; PneCr'p`t
� w wiIhS do.7000)nf Division Sof the Business and Professions Code,andmylicenm RFVT.4TnNr*T —jN HCILJSE US ONLY
milnneandefmct. ORIG. 302050052 , NO NEW PERMIT ISSUED
'"'q,� License Cors. Lic..
�y�a Dat Caatractm NO FEES- -PER POH Y.
ARCIIITEC'S DECLARATION
p0 c U 1 understand my plans shall he used as public records
uaiLLot— Licim.d Professional
OWNER-RUILDER DECLARATION
ay 1 hereby affirm that 1 am exempt from the Continue 'a License Law ho the \S
w—00 following reason.(Section 7031.5.Business and Professions Gavle:Any city or county \
d K g� which requires a permit to construct,after,improve,demolish,or repair any someone
cd iYJ+ poor it)its issuance,also requires the applicant hasnch penninn file asignedalntcrow
q <
that he is licensed pursuant mthe pmvisionsofto,Contractor's License Law(ChaperY Sq. Fl. Floor Area $297V"- n
a�Q (commencing with Section 70(10)of Division 3 oftbe Busimmesmd ProfessionsCMe)or
..
that he is exempt therefrom and On basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not marc than Rm hundred dollars($500). e Occupancy Type
❑1.as owner of the property,or my employees with wages as their sale compensation,
will do the work,and But snet..is not intended or offered for sale(Sec.70W,Business
and Professions Code:The Contractor's License law does not apply to an owner of 102 - PIERS equlred Inspections
properly who builds or improves thereon,and who doessuch work himself or through his
awn employees,provided that such improvements are not intended or offered for safe.If, 103 — UFER
however,the building or improvement is sold within one your of completion,the owner. 104 — REBAR
builder will have the burden of proving Nat he did not Wild or improve for purpose of
'al`) 105 - ANCHOR BOLTS
❑ I,as owner of the property,am exclusively connecting with licensed contractors to 10 6 — SEWER & WATER
construct the project(Sec.7044.Business and Professions CcAc:)The Convector's U.
venae law does not apply to an owner of property who Nods or impuwa Nemo.and, 202 - UNDERFLOOR PLUMBING
Lhocu �,biforsuch pumices with a contractor(s)licensed pursuant to the Contractors 203 - UNDERFLOOR MECHANICAL
I am exempt under Sec. ,B&P C for thisrcmon 204 - UNDERFLOOR FRAME
nee Date 205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATIONDECLARATION 301 - ROUGH PLUMBING
I hereby affirm under Penalty of perjury one of the Inllowing declarations:
I ham and will maintain a Certificate of Consent to selfi num for worker's Camper. 302 — TUB & OR SHOWER
sabon,u provided fm by Section 37(MI of the tabor Code,for the performance of the 303 - ROUGH MECHANICAL
workfnrwhichthisPetmitisissued. 304 - ROUGH ELECTRICAL
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3 05 - FRAME
3703 of the Labe,Code,for the performance of tb..,it for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are; 306 — HOLDOWNS
Carrier: Policy No.: 307 - INSULATION
CER I IFICAI E OF EXEMPITON FROM WORKERS'
COMPENSATION INSURANCE
308 — SHEETROCK
(Mi.section need not the completed iftbe permit iaforome hundred dollars($100) 309 - EXTERIOR LATH
"flea'') 310 - INTERIOR LATH
1 cenify that in the pcnbmtance of the work for which this permit is femed.I shall not 311 - SCRATCH COAT
employ any peman in any manner m a subject to become subjeco the W.deri Compensation
Taws of California.Data 313 - ROOF NAIL
Applicant
NOTICE TO APPLICANT It,afmrmaking oris Cenificale of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
hcfome subject In the Worker's Compensation provisions if the Labor Code,you..it 502 - FINAL PLUMBING ENERGY
0z forthwith comply with such provisions.,Nix permit shall N deemed revoked.
z 0 CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
4 1ho.hyaff,.dam me.isarnnsuuctionleadingagencyfor heimiumanccof 504 - FINAL BUILDING ENERGY
a > theve kfit,whichthis pnnitisissued(Site XA7,Civ.C.)
Lend505 - FINAL ELECTRICAL
Lq A
Lender's Name
aZ Lende,sAddmss 506 - GAS TEST
J0 I cenify in..I have eaJ this application and more that the anent information is 507 - FINAL PLUMBING
t~ conn.l agree mcomplywith all city and county ordinances and.state laws relating to
�U building construction.and hereby suthmim representatives of this city to enter upon the 5 FINAL MECHANICAL
ahavementiormJ PmPeny fnrinspeeti.n puelmses. 09 FIN
(We)agree In cove,indemnify and keep harmless the City of Cor nin r against
y Rabilities.judgments,nedprocosts rtyforand nsexpenses chompwhich may inany way eccroeagainst said City 5 N G
U 7 in consequence of the granting of this Permit, l/ f�
•7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT Issued by51 I WORKS Date l/
SOURCE.REGULATIONS.
Re-roofs C7 /
Signawrc of APPlicanVCommanr Dole
IIAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant or future
building occupant score or handle hanNous material
.hoed ny the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
e. 0 on2ssu(a>'r All roofs shall be inspected prior to an roofing material bei" Installed.
❑r.a ❑Nn P P Y g g
Will thr.ridi...i or future building oc'cupem use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hamrdous aft contaminants as de0ncd by be Bay Area Air Quality Management all new materials for inspection.
Dianicn/
El Yo ❑No
1 have read the havuou
Js m arrialshequimmenu under CbsdeT6.95 of me Califo,
nix liealm A SafnyCode,Sections 25N15,2333]and 255]4.1 understandthm if t e building
does not cufmndy haw a conam,that it is my responsibility to notify theoccupant of the
requirmentswhich must metpnoruoimuanecofa Cenifcmc of Occupancy, Signature Of Applicant Date
Owner or allLhOdWd agent Date All roof coverings to be Class "B" or better