04050048 (3) CITY OF CUPERTINO �" '�''" a € "
y� T �� ya �•r�
RUILDIN G DIVISION PERMT7 +G�.11V�CRACTO�At'INFC�RM, A\ i6
BUILDING ADDRESS: STEPHEN M SMITH PERMIT 16.4050048
192 RT &NnREWS A31
PERMIT ISSUE DATE
W NER'S NAME:
STEPHEN M S
/07/20
ONE: SANITARYNO. CONTROLNO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
400 LICENSED CONTRACTOR'S DECLARATION Job Description
j y 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 70M)of Division 3 of Ne Business and Prufessiors Code,and my license is
^ I.(at]force mdeffed. REPIPE /k���fpq feta.
viz License Class Lieq FII�®"'llgteLA�D
^ppp Dam Contractor
ARCHITECTS DECLARATION JUN 2 1 2004
1 understand my plana shall ha used es public record,
Licensed Professional
OWNER-BUILDER fDECLARATION BUILDING Y 3 1 hereby affirm Nat I exempt from Ne DECLARATION
tars License Low far,the g1Vi
pC following mason.(Section 703 1.5,Busia ns and Professions Code:Any city or county
x n which myuims a permit in construct,alcor.improve,demolish,or repair any Structure82000
ar--m prior In its issuance.also requires the applicant for such permit to File a signed statement
Mthat he is located pursuant mthepovisinnsofthe Connector's LicenseLaw(Chapter 9 Sq.Ft.Floor Area Valuation
ora (commencing with Section 7")of Division 3 o the Business and Professions Code)or
y dr t be,is exempt therefrom and the basis for dm alleged exemptlon.Any violation of
Section 7031.5 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 5 APR NI'ibdd 0 Occupancy Type
not more than five hundred dollars($500).
❑I.as owner ofthe Portnoy,m my employees with wages as their sole compensation,
will do 0tework.and the spectum lanmotended or offered ter sale(Sec.7044,Business - Required Inspections
and Profession.Code:The Convector's License law does not apply to an comet'Of q p
property who buildsto improves thereon,and who does such work himself or through his
own employees,provided that such improvements ase not intended oroRered for sale.If.
however,the building or improvement Brold within one yew of rnmpledon,the comas.
builder will ham the burden of proving that he did not Wild or improve for purpose of
Mic.L
❑I,as owner of the property,am exclusively contracting with licensed contratoo to
consumer the project(Sec.7044,Business and Professions Code:)The Contractor's Li.
cense law does not apply to an owner of property who Wilds or improves thereon.and
who contracts for such p rjecu with a eomvectoHs)licensed pursuant to the Contractors
License I.
❑l an exemptund.SSeeaa. B&PCfor Sir mason
0 i(! os-• '•cam?. Data
; �f
WORK^ 'SCOMPENSATIONDE LAryAT10N
I 1 hereby SIM.under,Penalty of perjury one el\.mss/allowing dalwations: _
❑1 have and will maintain a CertificateofCmmmOt tosel6insum for Workers Compen- -
sation,as provided for by Section 3700 of Ne Labor Code.for the performance of the
work for which this permit is issued.
❑I have and will maintain Workers Compensation Insurance,es mquimd by Section
3700 of the Labor Code,for the pnorarmantt of the work forwhich this permit is issued.
My Workers Compensation Insurance caoier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TMssection need nm Immmplemd lithe permit is(aro.hundroddnllara(SIM)
or less.)
1 moify that In performance of the work for which this permit is Is.ad,1 shall not
employ any in any manner so es to become subject to the Woo CMNemwion
Laws of CaT ia.Dates._r,�„/�, —�a I yT—s'
E TO APPLICANT'.'a after making this previsions
of tof he Labor
Carl you Should
Dune subject to the Worker's Com,or this provisions of the IaWr Code,you must
0 Oa forthwith rnmply with such prnviaines or this permit shall W deemed revoked.
Z,a CONSTRUCTION LENDING AGENCY ,
[r Ihereby aRrm that there 1.a consUuclinn lemdingagency for the performance of
ai> Nc week for which this permit I.i...od(See.3097.Civ.C.)
W Lender's Name
.7
Lender's Address
z
V 0 I certify that I have read Nis application and wrote that the about information is C iC
LA f~' m1mct.I agru to comply with all city and County on inanas and state laws relating to
OO loading construction,and hereby authorize representatives of this city to enter upon the
W shove-mentioned property for inspection purposes,
r (We)agree to Save,indemnify and keep hermios the City of Cupertino against
M Ny liabilities.judgmente,costs and expenses which may in any way accrue against said City \ (J
his
C) in of the granting Ofr'^ APPLICANTCUNDERSTANDStANDc WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
SOURCE RE L IONS.
Re-roofs
nature of pplicaHAZA DO m
HAZARDOUS MATERIA CLOSURE Type of Roof
WIII the applicant or future building e,Chapter
or handle Health a material
defined by the Cupertino Municipal Cade,Chaplin 9.12,and the Health end Safety
. Coda,section 25532(al7 All roofs shall be inspected prior to any roofing material being installed.
❑Tea tomo
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
r emit Immmnua Dir conmmi unss as defined by Ne Bay Arca Air Quality Management all new materials for inspection.
District?
[3 yes u
1 have mad the harardnus materials mquiremam a under Chapter 6.95 of the Cali(or.
nice He
Saf yCade,Smones 25505,25533 aad2534.1undersmnd ounifdm Wilding
docs not rtently hax a tenant Nat it is my respeasmility to nodl'y the occupant of the
I ones which must bemet poor tuissuance ofaCenifcj¢ofOccusnc Signature of Applicant Dale
�f All roof coverings to be Class"B"or better
3(i �tnac � = 30 t
tt E�4 ? Gam- t t,
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APPROVED a = Apt
M ACCORDANCE WITH THE CITY of 3f Q
Gll1.'fATl�t+: ,DES AN' OnOMAN=
OATg,
D
3t� SIGNE _
This set e` ply-sand specifications fAU57
be kept ,, me job at all times and it is un
• • lawful to make any changes or alterations
M same without written permission trop
the building Dept., City of Cupertino.
The stamping of this plan and speciflcstioncs Y7
SHALL NOT be field to permit or to be gn'.
yn' approval of the violation of an prowalon" '
if anv MOrdinance nr Stnta any
It
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