03050159 (2) CITY OF CUPERTINO W, d e�"tQ *`
BUILDING DIVISION PERMIT �orrrl�cTOR TNO,RIVIATIONt,� .,
BUILDING ADDRESS: HUMRICH CONSTRUCTION PERMIT N003050159
7898 ROBTNDRT.T. WY
ER'S NAME: 2995 WOODSIDE RD #232 PEH"T"`S1Y3 �0/,2003
WSON CARL D AND
PHONE: (650) 369-0999 SANITARY NO. CONTROL NO.
ARCHITECTENGINEER: BUILDING PERMIT INFO
BLDG EI.P.CT PLUMB MECH
a 8 6 LICENSED CONTRACTOR'S DECLARATION JobDescri tion
rd 1 wmby affirm Nn 1 Am Hwrax r previsions of Chapter 9(commencing P
wohS7")afDivldan 3 of the Bu and Prafeuium a IkanwI,
O� infa110 deif (/ REVISION--IN HOUSE USE ONLY
NO NEW PERMIT ISSUE, ORIG. #02060022
B ARCHTECI'S TION
1 understand my plans shall he used u public reemda
O
`udLiccoad Professional C _
OWNER-BUILDER DECLARATION /
.� F I hereby mnnn Nat 1 am exempt from the Contractors License law far the
yO o following moon.(Section 7101.5,Business and Pmfmions Cade:Any city or..my - (�
H$2 which requlfca a Permit to construct,Alec Improve,demolish,nr repair my armoan V
_Zr prior m its iuuence,also requires tw applicant far Such Permit u Blea signed statement
< that W is licensed punuanuo the provisions of Oc Contrwtor''sUamc Law(Chapter 9 Sq.Ft.Floor Area `T Valuation -
�a (commencing with Section 70DO)of Division 3 of Ne Business Said Proressions Code)or �l C0
.. that he u m exempt therefmand de basis for the alleged exemption.Any violation of Y
Section 7031.5 by any applicant fm a permit ubjects the Applicant o A civil penalty of APN Number Occupancy e
not mart than five hundred dollen($500). P y'►YP
❑I.ummoftlupmpcny,.mycmplaymwWwguuuekwkmmp don. 36219026 ' 00
will do Omwork,and the awcturt how mended oroRertd forssle(5..7014,Buzi.
SuOO
And PrefeulOn,Code:The Connector,License law dam rem RRS�
Out apply an Owner of 101 - FOUNDA'1'MfId Inspections
property who build&or harrows themon.and who dm mch work himself orthrough his
....play..,provided Oat uch improvements Ater,imendedara0ertd ran Wer.if. 102 — PIERS
however,Ne building or Impmwmeat is Sold within arc year of mmpleuan,the onvoer.
builderr wlH hava the burvicar Of provirt,that M did San Wild or improve far parroome of 103 - UFER
1r,') 104 - REBAR
❑1,AS owner of the property,am exclusively contracting with licensed contncurs to
Constnet the project(Sec.7W,Business and Profwions Cade:)Time Commcur's lb 105 — ANCHOR BOLTS
come Law dm not apply in an owner of property who wilds or improves demon.and, 106 — SEWER & WATER
who contracts for such projects with aconuwur(s)licensed purSuant to the Contractors
License law. 202 - UNDERFLOOR PLUMBING
❑l em exempt under Sec. .B B P C for this reason 203 - UNDERFLOOR MECHANICAL
er Date 204 - UNDERFLOOR FRAME
WORKER'S COMPENSATION DECLARATION 205 - UNDERFLOOR INSULATION
1 hereby affirm under penury,of perjury ane of the following declanlions'. -
IhawandwillmaintainACortlOCoteofConxenuoaelGlnsure forWorkcr'sCompcn- 301 — ROUGH PLUMBING
union,as provided for by Section 77011 of the labor Code.(or the pert rmarce of the 302 - TUB & OR SHOWER
work for which thlS Perm it is Wood. 303 - ROUGH MECHANICAL
❑1
have
and ' maintain Workers Compmsauon InsurwCo,as mgWme by Stolon 304 - ROUGH ELECTRICAL
3700 of me Lab od0.ror me performance Myl(�woh Tran which this permit is issuW.
My Work C mpemenla. C.
cemcr oliry m _,1 305 - FRAME
c.rti°. Pe"'y Na: 306 - HOLDOWNS
ERTIFIC TE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 307 - INSULATION
(IhiswLl..oeed not wcompleted lithe permit is Trans.hundrcddollars(SI(1f0 308 - SHEETROCK
or less') 309 - EXTERIOR LATH
I Coolly met in the perform...of the work for which this permit is blued.I shall nut 310 - INTERIOR LATH
employ any person in Soy mw. u u
r an become Schlott to the Workeri Compewdon
L,waofCalifornia,Data 311 - SCRATCH COAT
Applicant
NOTICE TO APPLICANT:If,after making this Cenifcalc of Exemption,you,hould 313 - ROOF NAIL
b.comeaubj.t to the Worker.Compensation provisions of 0.labor Code,you mum 501 - FINAL ELECTRICAL ENERGY
.J,Z foMwith comply with such provisions or this permit Nall w deemed mated.
zCONSTRUCfIONLENDINGAGENCY 502 - FINAL PLUMBING ENERGY
a> ucwhihmba B redealthemisaconslmctionlendingagencyforthePerformanceOf 503 - FINAL MECHANICAL ENE
mcwurk
m Lander',Nwe Penntied(Sec.J097,Civ.CJ 504 - F I NAL BUILDING ENER
D LeadersAddmss 505 - FINAL ELECTRICAL
U O 1 certify mal I low n an
read this applicatiod starts, ew
that the w fnforo atiun is 506 - GAS TEST '
U.f correct.I gree m comply with all city tad county ordinances and state laws totaling to
OU buildingconawction,andherebyauthodrtteprcxentmiwsofNisCitymcrierOunthe FINAL PLUM BI G
[11 alaw-mentioned property for inspection purposes. VO8FI(We)agree u taw,indemnify and keep harmlut the City of Cupertino againsty incoitiatfien ments.cosuud expensnswhich may in any Soywrntespin&raid Citya5L�immnuquenlimc ting of this expeneswii I{4•�'U,APPLICA N AN 5 AND WILL COMPLY WITH A NON-POINT Issued by: NG Date50 RCE y N5. 3 Re-roofs _
IL
SSi darer of plISO ,2mswtor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WI theapplicam or future holdingsupanteueor handle hevardous material
AS defined by dre Cugh5K. �'
5ecdat us3z()± All roofs shall be inspected prior to any roofing material being installed.
Yu WBI Or appuawtSibling Occupant use equipment or devise which If a roof is installed without first obtaining an inspection,I agree to remove
emit havardaus airconuminants defined by the Bay Arca Air Quality Management all new materials for inspection.
M11 ict7
❑Yex u
Ihave marl thsm 'al,requirements under Chapter 6.95 or the Califon
b6a,25533.d25534.1..��dd�gifthebuildinjo 505,15537and2553a.lundcruandmmlfmewilding
that it kmy to,ponsibtlityunoulyPeo.upemOffie
elpuoruismanceafacerdfk,u a pw.y. Signature of Applicant Date
net Otolbal.d.gCm - Date All roof coverings to be Class "B" or better