02080099 (2) C[em oNcov SONO
iNPERMIT CONTRACTOR INFORMATION:
.
By2114 #�DRSHANNON CT CONTROLLED SYSTEMS OF CALIF.PERMIT 02080099
D�15�T ARTHUR J AND CHARLOTT 2 2 8 3 MORA DR APPucAz Qf$ s j Al 002
PHONE: SANITAR(YJ 2N�O/. 1`1 CONTROL NO.
(415) 964-8354
O O ARCHffECTIENGINEER: BUILDING PERMIT INFO
�u BLDG ELECT PLUMB MECH
za u 1=J =1 I-=
ss.. 2 LICENSED CONTRACTOR'S DECLARATION
ZO Z I hertb ffrm that 1 am licensed unQersprovisions of Chapter 9(commencing Job Description
Fytqq with Sectio )of Division JofNeEuay�QQEVs and Professions Cede.and my license ADD A/C (4 TQN)
_ai se is in full( d Re�rt. F=1
ASE®
raise
6 Liccnu ass e d o C O Lic.p Z �
3 w I an I ARCHITECT he
ed RATION JAN 2 2 2003
C g I understand my plans shall be usetl az public records
S wyY
rd 6 a O Licensed Professional
c OWNER-BUILDER DECLARATION R�
,n 1 hereby atfrm that 1 am exempt from the Conant License Law for Ne WILDING $3225
G?< following reason.(Section 7031.5.Business and Professions Code:Any city or county
F O which requires a permit to saute alter,improve demolish,or repair any simulate
au prior to its issuance.also y res the applicant for such permit to rile u signed statement - - - - -- ----- -- --
c� ¢� .... ........
that hes fireated parsbat to7Ne Provisions of Ne Ce Business
sand Pr Law(Chapter 9 :Z s�6StIOffiO&ldor®s�51NY TS'pp i h Valuation
(commencing- with Section]g10)of DivisonJo(the Businw and Professions Cale) _.,, , l ,.�r•.. [_aa pa.3se l l{9,\,
or that he is esempt therefrom and the basis for the alleged eaamptfun.Any violation -
of Section 7031-.5 by any applicant for a Permit subjects the applicant to a civil penalty
mrnnt mare than eve hundred dollars Issoul. 3 01ARN lE OMW PLUMB IN "1':- Occupancy Type
°1,as owner of the property or my employees with wages a their sole compemsa[ion, 303 — ROUGH MECHANI AL
will'do-the'work;and the"saucmre'I,not intended or offered far sale(Sec:-70a.r," 3 O4 - ROUGH E aj � CIIOn$ t
Budness and Proerslma,Canam
e Contractor's License Law does not apply to an
...at of import,Who build m improvesmaram,and who d«s such work himself 501 - FINAL ELE TRICAL ENERGY
or through his own employ...provided that such improsemems are not intended or
oHeredTot
aaic.If,however, he WEdmg or improvement,,sold lJhbin obeys.of _........ 502 ___..FINAL PLUMBING ENERGY.___...
`mpsoernpur,"wafbsale')r will have the burden of proving that he did not Will or 503 - FINAL MECHANICAL ENERGY
..pl.uownez of the ppeny,em"cluswely' "'g . ... ... . .... .. ....505----"FINAL ELECTRICAL ..---- - .......
co Professions
with Icenxde Ciaacmrsm
- License the project(Sec, toa,eastern anddeny who
CWeDTheues tmnors 507 — FINAL PLUMBING
License Law does not apply, an owner of intim,won Wilds sed amves Norton, -
_and_wecia'a contracts for mch.projecn wim.a.convactorts)licensed pursuant m the _ .._.508.-._--.FINAL-.MECHANICAL-----.-.. .- -
' s+ Commctnrx License Low. .
°lameaemptundersed ,B&PC for mit mason
Osvner't� Date
" WORKER'S COMPENSATION DECLARATION
pp I hereby ant under penalty of perjury one of the following dedaradons:
",1•. ° 1 Wve'and will maintain a Crmfifine of Conscut on self-in...a for Worker's
Compensation, as provided for by Section 37(10 of the Labor Code, for the
Performance of the work for which this permit is issued
°I have and will maintain Worker's Compensation Insurance,as required by Section
37W of the Libor Code.for the performance of the work for which this permit is
issued.My W rker's Compo ton laid are c 'c y
nd P li ,jnupmber are
�Carts r Ct ) sec Cwt?Pal yNo 60 a / GS 70 ,I t t j
r "CERTIFICAIGN OF E%EMPI'1 FROM WORKTTS�" ` k i. k 9d �, rr5S4 f .r 9,p ]LJiT
. .. . OMPENSATIONINSURANCE ................_
.. !i. - t
'(This action nceJ not W cnmpletW if the permit is for one hundred dollen 1. its
LEI W)or less.)
9 nay th i er pet nonce rte k f h hat t is a l
'shall oat employ any person in any m nor iu as io become subject rt to m<Workekcri
Compensation Laws of California.DAie '
Applicant
NOTICE subject
APPLICANT:Work IL Compenser ation
ntPr Provisionates
of the Exemption,you you ld t.
z
become su amply the Worker's Compensation provisionsll theeeWr Cede,you must
OQ;
forthwith ' tiPlY with hprovisions o thisPermitshall he deemed revoked. ",_,•-•, .,.,._ .._..___.. ....._ _ •' .. _.. ...
t CONSTRUCTION LENDING AGENCY t
a;7 1 hereby affirm that there is a c6natraction lending agency for the performance
y"e .(me work for which thrspermns issued(Sec.3097.Civ.C.)
..Lenders Name'. •-'. .-__ ___......
Z)-.Z L cmk,'s'Addmss'•
C.70 I cenify that I have rend this application and state that he above information is
h:Ew come[:1 agree to comply with all city and county ordinances and state laws painting
i' U to building conmmction.and hereby authorize represeinmives of this city to enter upon
>,:'(yj theabove-mentionedpmpeny f«inspection puryores.,
t (M'e)agree to save indemnify and keep hermlees the City of Cupertino against
rA liabilities,judgmen4 costs and eapu
ens which may in any way arcane against said V
V,,,z City in consequence of the granting of thisLL peman
APPLICANT UNDERSTANDS AND WICOMPLY WITWALLN -P INT
- SOU REL'(N. Issued byt Date
S" m e" plicanVCmmmnor am Re-roofs
HAZARDOUS MATERIALS DISCLOSURE [
', building«c pant stare a handl bazardous ma¢nal .Type of Roof
e Cupertino
Tut WJd _
C d : m the Cupenm M i tQal Cede Chapter9.11,and th Health and Safety
_ �'i
Core:Sect o 25532(} 1_L t' t �.I ,l i 1 I , ^a Std"I-'�tl.l
°v' ( All roofs shall be inspected prior.to.any.roofing material being installed
Will the applicant orfumigWildingoccupant use equipment or devices which If a roof is installed'without first obtaining an'inspection,"I agree to remove
emit haramous air comaminana,defined by the Bay Ares An Quality Management
District?
all new materials for inspection Applicant understands and will comply with
-,
0yes all non-point source'regulauons;
1 hove read d hazardou materials m aimumats'under Chapter 6.95 of the
Cahlomm Health&Safety Gde.Soriano,25505.M533 and 8534,1 understand that
if the building d«snot currently have atewm,that it is my responsibility tonotifythe - - -
'occupeht of the requiiemema which most be me,prior m ism ce of a CeniR-ate of
Occupancy. „ Si nature of A hc, _ Date
'owner or a rl d og t Date I All roof coverings to be Class "B" or better
2r:.�:.._.a:::.,•::_ -OFFICE.. _.... __ _... ...._. . . _ . .._. - -- -