03010042 (2) CITY OF CUPERTINO +' "'��€ •v b �a �. "
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BUILDING DIVISION PERMIT CONTRACTORANFORMATIONxsawa
BUILDING ADDRESS: PERMIT N00 3 010 0 4 2
21670 STEVENS CREEK BLVD aama
R'S NAME: PERMIT ISti�t�y-o 4 2 0 0 3
C HO
NE: SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
99,
+�O p LICENSED CONTRACTORS DECLARATION lob Descn [ion
1 InNat mby affirm 1 am m
licensed uor provisions of Chapter 9(commencing
mIN Section 7")of Division 3 of be Eastman and Pnfessions Code,and my Iiconse is F�1 NAL.E[�
full to=and effect. TI--RESTAURANT
j yrs? LLeense Class Lic.0
Deo, Cenlrasor
YARCHfmE DECLARATION JUL' 2. 9 2003 .
Y+y+ 1 understood my pans WWI be mixed as public mosses
In
mare Licensed Professional
='0 OWNER-BUILDER DECLARATION BUILDING
I hereby aflrm that I am exempt from do Contraction License Law for the
j:00 following mason.(Section 713 L5,Businss and Profession Code:Any city or county
39 which requires a permit to construct,eller,Improve,dcmolah.or repair any street..
fora prior to its issuance,also royui.s the applicant for such Permit o file a signed sentiment
C�eQ Nal he is licensed pursuant to the provislenof the Contractor's Lima.Law(Chapter 9 Sq.Ft.Floor Area tion
e( (commencing with Section 7")of Division 3 of 0.Embroil Prolead ns Codc)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Setdm 7031.5 by any applimt fa.pewit objects the appltemt m a civil p alty bf gr Occupancy Type
not mom than five hundred dolara(S500).
❑I,u.wneroftliepmpeny.mmyempl y withwrsuUo4wlecompewdon, 103 _
will do the wok,and dwimucwm la mourwrded muff red forsaLe(See.7044,Bushman
and Prefe non Cede:The Committers Llanse law awes lel apply in an.weer of 102 - PIERS Required Inspections
property who Wilds crimpmva themem,and whodauuchworkhimselforthrough his 103 - UFER
own employee,provided Nre al such improvements anot intended or.Re od for We.If.
however,the building or improvement is sold within one year ofcompletlon.rile owner- 104 — REBAR
Wilear the WNm.fprovingthathedid out Wild orimpr.mfmpumeseof 105 - ANCHOR BOLTS
I.
❑1,as owner of the property,am exclusively connecting with licensed marmosets in 106 - SEWER & WATER
construct the project(See]sod.Bninsas am Profession;Cres:)The Commences Li-
sense202 Law dote not apply.an owner of property who builds or improv.dan
emon, d,
who nomads for web projects with a conmecot(s)licensed pursuant to do C.ntracmea 203 — UNDERFLOOR MECHANICAL
License Law.
I am exempt under see ,B&P C for this reason 204 - UNDERFLOOR FRAME
Dae 205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATIONDECLARATION 301 - ROUGH PLUMBING
I hereby affirm under Nulty of perjury one of the following declarations: 302 — TUB & OR SHOWER
p than and will maintain eCenlriaeofConsent tosel6inwre forw.rkersCompen. 303 — ROUGH MECHANICAL
cation,u provided for by Section 1]00 of the Labor Code,for de Perforations,of the
were for whim this permit is issued. 304 - ROUGH ELECTRICAL
C]1 Nae and will maintain Workers Compensation Insurance,as required by Saturn 305 — FRAME
370o.rdef,bncede,for d.performenceefthewerk(.rmiCh this pereskissusd. 306 HOLDOWNS
My Worker.Compensation Insumnce carrier and Policy number arc:
Carrier: Policy No.; 307 - INSULATION
CERTIFICATE OF EXEM MON FROM WORKERS' 308 — SHEETROCK
COMPENSATION INSURANCE
frbawmien wed ran W completed ifde permit Is rue..hundred do[].(SIM) 309 — EXTERIOR LATH
orleaa) 310 - INTERIOR LATH
I artily Net in the perfmmence of the we*for which this Permit a issued.l Nall not 311 - SCRATCH COAT
c Jay any person in myWismar wulobecome subject wthe WomeriCompensation 313 — ROOF NAIL
ws f California D.
APPlio5i 501 - FINAL ELECTRICAL ENERGY
NOTICE TO APPLICANT:IL after making this Campeau,of Exemption,you should
become subject w Ne Womeoa Compensation provisions of the Labor Crow,you most 502 - FINAL PLUMBING ENERGY
,JZ1t
fowith comply with such provisions or this Permit shall he deemed rewired. 503 — FINAL MECHANICAL ENERGY -
ZO
� CONSTRUCTION LENDING AGENCY 504 - FINAL BUILDING ENERGY
[.� Thereby affiem that them is a construction Lending agency for the performance of
the week for which this permit isissued(Sm.3097,Civ.C.) 505 FINAL ELECTRICAL
sop IendwrsName 506 - GAS TEST
7 0 Landers Add. - .
U O I modify thI hoe read this application Information sato that the show Informon is 507 FINAL PLUMBING
correct.l agree to comply with all city and county bNinanas and now Taws reaung to
508 — FINAL MECHANICAL
0U building convection,and herebyaulb.rim representatives of this city to error upon the
mown-menuunnd PMNny for Wpreuon Particei 0 FINPA GRADE
(We)agree to ave,indemnify sod keep harmless the City of Cupertieo against 0 FIN 3
Ilablli0es,judgmsnu,cosu no expenses which may in soy way accme against said City —`
U F77 In cense nm of the grmning 0f LMs permit. 51 — A —W -
APPL ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-P INT Issued by. i Date
SO CE REGULATIONS.
C14 Q Re-roofs
ignatue of ApplicanVCmnmacmr I Da
/ HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will do.pplicam or(unit.Wilding occuparatnom ter"note huudbn memo.]
flood by the CupertinoMimidpa Code.Chan
apmr 9.11. d the Health sod Safety
e,Scott..H531(a)? All roofs shall be inspected prior to any roofing material being installed.
❑re o
Will the applicant or future building occupant use equipment or dcvicn which If a roof is installed without first obtaining an inspection,I agree to remove
cult harardoua air cim inmu u d ed by de Bay Area Air Quality Management all new materials for inspection.
1 District?
QYe u
I have reass the hoard smar.rud requirements under Clupor6.95 blow Califs- t
na HalthhSafclyCodeISectons 15505,25533 and 25534.1 undcrwmW but lithe Wilding
dove I currently haveIs .mnm4 Nu it a my respondhiliry a mtily do oaupml of Ibc
coq remontsw'chmutWmslpri.rwinuma.faC=rwam.fOcc/pancy� Signature of Applicant Date
Y(/ O
wnwror authmived agent Dam All roof coverings to be Class"B" or better