03060019 (4) CITY OF CUPERTINO
BUILDING DIVISION PERMIT ,ONfRACTOR INFOI2MA I®N
Bm1.Dl"GeoDRFss: TERRY BROWN, GEN CONTRALTO EaMIT"g13060019
10491 SCENIC BLVD
NER'S NAME: 14510 BIG BASIN WY FERMITI3%T6'M3/2003
,ESE, MARY E.
ONE: S—1640 SANITARY NO. CONTROL NO.
ARCHI7ECTMNOINEER: SUIIDINO PERMIT INFO
BLDG ELECT PLUMB MECH
ee 0 0 0
Ypp LICENSED CONTRACTOR'S DECLARATION Job Description
1 Imreby"ran Nal I am licensed under prevision of Chapter 9(commencing p
wish Swedes 7IXI0)or Divi,lon J of dm Busircss atW Pro(vasiun Cade.and my Iicmse u n
uranmreeand eBea ELE R�CAL��R,WIR %'JE
TON, ADD BATH
z Licence Class Lie.N yyy..fffzgDam contractor TO OTTAG ), VINDO EME SIDING
ARCHITECTS DECLARATION ✓I understand my plan shall W used as public records
11
Licensed Professional —
OWNER-BUIIDER DECLARATION
Z I hereby efrom that I am attempt from the Canuactora Licenm Law far the
En O following mason.(Sweden 7031.5,Business and Profession Code:Any city er county
$ which requires a Permit he mistrust,after.improve.demolish.or repair Noy s rucmm
^ prior m its issuance.Jmmquires the applicant far such permit m Ele a signedaumment
4�
< Nat he is licensed Pursuantrothe provisions ofthe Contractor's license Law(Chapter 9 Sq.Ft. Floor Area Valuation
a (commencing with Section 7000)of Division 3oftheBushwasmlProfessionCort)or $26000
Nat he Is exempt Nattiness and dm basis for the alleged exemption.Any violation of
Section 7031.1 by any applicant for a pemeiuubjects Ne applicant to a civil penalty of APN Number Occupancy 71}pe
not mom Nan fife hundred dmlses(5500). 35706001 . 00
.
O 1,as.of the property.or my employees with cages sa Neh mm compenadm,
will an I.work.and dm anwerne m at intended ora@red for We(Sec.7044,Business eChOOS
and Profewimu Code:The Commerce,License Law does ret apply m m owner of 101 - FOUNDAp�n#dins p
property who Wildsw improve,Nermn,and whodoessuch workhimselfwNmugh his
awn employees,provided that such Improvements arc not Intended oroRered(wade.If. 102 — PIERS
however,the building or impmwmmt is sold within am year ofmmpledde.we owner. 103 — UFER
builder will Mw,the burden of proving that W did not Wild or improve far purpose of
sale.). 104 - REBAR
❑I,as owner of the property,w ettclusiwly eanuacting with licensed commumn,m 105 — ANCHOR BOLTS
construct IN,project(Sea 7014.Business and Profession Code:)The conswu rs U.
«rte law don nor apply to an owner of property who Wilds or imprew theme.and. 106 — SEWER & WATER
who conuacu roe such prejecu with a emummr(U licensed pursuant in the Commutes 202 - UNDERFLOOR PLUMBING
Lkmm Law.
❑lame: tunder Sm. BS P�Cfim�p2ts/e/�esIm-� 203 - UNDERFLOOR MECHANICAL
/
Dow�'o/ 204 - UNDERFLOOR FRAME
WORKER'S COMPENSATION DEC TION r 205 - UNDERFLOOR INSULATION
Ihemby affirm mar pewty or perjury rete of dm following eealaradom: 301 — ROUGH PLUMBING
�� ❑Iluve and willmJnuinaCWfiwmof Consemuself-InumfwWwtresCompen-
astion,a provided for by Samon 3700 of IW Labor Code,for the performance of we 302 - TUB & OR SHOWER
work for which this permit is issued. 303 - ROUGH MECHANICAL
❑1 have and will maintain Worker's CompensNon Insurance.ss required by Section 304 — ROUGH ELECTRICAL
J700 of to Labor Code.for the performance of the work for which this permit is issued. 305 — ]'',BANE
My Workers Compensation Iruumne carrier and Policy number an:
Carrier. Policy No.: 306 - HOLDOWNS
CERTIFICATE OF EKEMPTION FROM WORKERS' 307 - INSULATION
COMPENSATION INSURANCE
(This=I.head ace,Ito comple"iflK permh m faro¢hundmddollan(SIM) 308 - SHEETROCK
0tma) 309 - EXTERIOR LATH
1 certify that In lie performance of the wart for which this Permit is issued.I shall nor 310 - INTERIOR LATH
employ any person In my manner an as an become subject to lM Workere Compensation
Laws of Caliromia.Dam 311 - SCRATCH COAT
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you shouW 313 - ROOF NAIL
become subject to the Wallace,Conformation provisions of dm faWr Cove.You a= 501 — FINAL ELECTRICAL ENERGY
z forthwith comply with such provisions or this Permit shall W deemed m clad.
Z O 502 - FINAL PLUMBING ENERGY
CONSTRUCTION construction ON LBNOTNOAOENCY 503 - FINAL MECHANICAL ENERGY
IWmby aRrm dust CONSTRuIONLENLENDING
AGENCY
for Ne performance of
a? the work far which this Permit itissued(Sec.3om.Civ.C.) 504 - FINAL BUILDING ENERGY
W7 p
Leaders
7 LadWer.AddreAUress 505 - FINAL ELECTRICAL
.,� Is
U O I certify that I how rood this application and tum Nat the aWve information u 506 - GAS TEST
I. correct I agree in comply with all dry and county aminances and sum laws miming an 5 FINAL PLUMBING
O Wilding construction,and hereby auNwim mprosenutim of this City re enter upon dm
4V ahovumcndonnApmpcnyfor inpectionpuryoses. 08 FIN MEC C L
(We)agree In saw,indemnify and keep homeless the City of Cupertino against N
liabilities.juCgmam,,ewu and cap..which may In any way same against said City 5 F DE
U in cwuequm"of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ONPOINT Issued by51 NG Date
SOyg� ULA�IONS.�" `
_y � !//o'�G�-- 6 7 03 Re-roofs
S eahof Applican✓Comracmf a t Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will we applicant or future building wcupenl term or handle hvamow material
as trained by the Cupenina Municipal Code.charm,9.1x,and the Health and Safety
Alki,ci..See❑dom 25532(a)?7 All roofs shall be inspected prior to any roofing material being installed.
Yes shy a
Will the applicant or future Wilding azupant use equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
emit hweardnus air conuminanta as dc0hed by the Bay Amo Air Quality Matugcment all new materials for inspection.
District?
❑Yes WN.
I haw mW the havardnusmaterials requirements under Chapmr 6.93 Carlie Califon
nice Health&Safety Code.Swdon25505,25533 and25534.1 understand that lfdm Wilding
does not currently haw a mom,that it u my mspmISHIRity u dfy tic aeeupant of Ne
myui m t muatWmet wmissuaneeofaCcttifKam (0.c Signature of Applicant Date
J/ G 3�d3
Owner or authorized agentI Dd. All roof coverings to be Class"B"or better
T