03090007 (2) CITY OF CUPER"LINO w�-�'"'? A ' >'i" -?
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION "„?
. M
BUILDING ADDRESS: GEORGE TU PERMIT N003090007
r
OrR'SNAME: PERMIT ISSUE DATL
GEORGE TIT
: SANITARY NO. CONTROL N,
ARCHITECTN NGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION
I C 1 hereby affirm Nat 1 sin licensed under provisions or Chapter 9(commencing lob Description
bW with Section 7M))of Division 3 of Ne Business and Professions Code.and my licwc is
-oF in full force end effect.
,qz Liansectasa Lic.g REVISION/BATHROOM
Dam Contractor ORIG PERMIT x#03080016
7W ARCHrECrS DECLARATION
I understand my plans shall he used in public records IN HOUSE ONLY-NO NEW PERMIT
4�U
yp Licensed pmressional
OWNER-BUILDER DECLARATION
<Z I berchy.(Sere Nat 1 am exempt from the Contractor's Code:
License Law for the
❑O following retina arch t Rf3L5.Business and improve,
Ins demolish,or Any city m county
which rets is,o a permit re cnnswn,olmc i t forsu ermittor repair any structure
prions its lensed pursuant
requires the applicant of roesuch Permit MCA cense Law(Ch einem
¢ <
(comthat mencing
incingWithS(suam7")ofDiviomofthe oftheBuiness nimnscliws,Coxier9 Sq. Ft. Floor Area Valuation
z S Oat he is exempt
ad the
Division r the
theeged Business and Any
vi COJe)err
s, Nat he is aemph therefrom and the buY for the alleged exemption.Any violation of O
Section 7031.5 by any applicant for a permit subjects the apprcaut to a civil penalty of APN Number Occu anc Type
not more than five hundred dollars($SW). - -- - - .._. ____ . _... .. .. .,._-. _._. P .y yP
❑I,uownerofthepmpeny,ormyemploycawiNwa uNekmlecompenution, 35708004 . 00
will do the work,and the shmervm is not intended or offered for sale(Sec.1044,Bminas Required Inspections
and Professions Code:The Comeactor'a License Law does not apply to an owner of q p
property who builds or improves thereon,and who does such work himself or through his
owncmployces,provided Nauuch improvementaan nmimmmded oroRered foraale.n. 101 — FOUNDATION
however.the building or improvement is sold within one year of completion,Ne owner
builder will ban the burden N proving that he did not Wild or improve for purpose of 102 - PIERS
Sal,.).
1,as owner of the property,am exclusively contracting with licensed conbators to 103 - UFER -
Construct the project(Sec.7044,Business and Professions Code:)The Contractors U. 104 - REBAR .
cove Law does not apply to an owner or property who Wilds or improve h,emon,and, 105 - ANCHOR BOLTS
who contracts for such projects with o comeactor(O licensed pursuant to the Conuactitts
Lic nsc Law. 106 - SEWER & WATER
! exempt under Sec. .B&PCforthismoon 202 - UNDERFLOOR PLUMBING
rMPENSATIONOECL Ann -)_u 203 - UNDERFLOOR. MECHANICAL
I hereby offum under penalty of perjury one ofthe following declaration: 204 — UNDERFLOOR FRAME
I base and will maintain a Certificate of Consent o solf-iaure for workers compere 205 - UNDERFLOOR INSULATION
action,u provided for by Section 3100 of the Labor Cord,for the performance.(.he 301 - ROUGH PLUMBING - -
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,ex required by Section 302 — TUB & OR SHOWER
3100 of the labor Code,for the Perfomorec of the work for which this permit is issued. - 303 - ROUGH MECHANICAL
My Workers Compensation lmurase carrier and Policy number are: 304 — ROUGH ELECTRICAL
Carver: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS' 305 - FRAME
COMPENSATION INSURANCE 306 - HOLDOWNS
or Iced(Thls section need not be complewd if Permit is for one hundred cohort(5100) 307 - INSULATION
1 certify Nat in the performance of the work for which thin permit is issued,I shell not 3 08 - SHEETROCK .
employany Pearn in any manner m as m Wcome subject o the Wmkeri Compensation 309 — EXTERIOR LATH
Ipwa o(Califomia.Dare
Applicant 310 - INTERIOR LATH
NOTICE TO APPLICANT:IL alter making this Ccnificam of Exemption,you should 311 - SCRATCH COAT
become subject to the Worker's Compensation previsions or the labor Code,you must
�z forthwith comply with such provisions or this permit shall be deemed revoked. 313 - ROOF NAIL
ti O CONSTRUCTION LENDING AGENCY 501 - FINAL ELECTRICAL ENERGY
I hereby ofrtrm Nat there is a conawction lending agency lot the performance orIII: SO2 - FINAL PLUMBING ENERGY
44 ; he nder's urwhich this Permit Itissued(sco.9(191,Civ.C.) 503 - FINAL MECHANICAL ENERGY
Y Q Lcnde,'s Name
Lender's Address
z 504 - FINAL BUILDING ENERGY
I certify that 1 have read this application and sham that the above information is 505 - FINAL ELECTRICAL
y correct.1 agree to comply with all city and county ordinances and state laws totaling to
�.� building Construction,and hereby auhhorim representatives;or Nis city to enter upon the CTAS EST
ver above-mentioned property for inspersion purposes.
(We)agree to Save,indemnify and keep haemins the City of Coalition against 0 7 F I
N Iiablllhea,judgments,costs and cxpcescswhich may inanyway accrue against said City S ICAL
Jz in eonsequerma of the graining of this permih. /f ”,
^' APPLICANT UNDERST DS AND ILL COMPLY WITH RILL NON-POINT Issued by:5 Dale
SOURCE REGU
00_A03'
Re-roofs 510 NAL PLANNING Buie 5 4 - INAL PUBLIC WORKS
RDOUS Dam MATERIALS DISCLOSURE Type of Roo
Wilby a CupertinontorMfuture"a[building occuhapter 9.12.handle Health
and Safety al
cOncd by the Cupertino M hmpal Cafe.Chapter 9.12.end hW Health ono Safety r
r' Section25532(an All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
Will the applicant r mtom uildlegrccupanh use equipment or devfas which -If a roof is installed without first obtaining an inspection,I agree to remove
chill h solous air contaminao defined by the Bay Arca Air Costly Management all new materials for Inspection.
District
❑Yes is
Joan.
have mad the Wrath usmamriak mquimmenu under Chapmr 6.95 rf dm Califon
Iia Health&Safey Code,Sections 25505.25533 and 25534.1 understand Nat it the building -
Jccr not cunemly hew a mnank in it u my msporuihiloy m notify the mcupmt of the
mgwmments wni isstrma cart cenir am nraapanny Signature of Applicant Date
�N
Date All roof coverings to be Class "B" or better
i