03020120 (3) JILDINGADDRFSS:
Y OF CUPERTINOa ' `UILDING DIVISION PERMIT ;CONT, OTQRANFORM, N EY COMPANY PERMIT NO.
1760 STEVENS CREEK BLVD 03020120
'S NAME: 19 S 3RD ST PERMITISUEDATE
C SHANE THOMAS J AND BIRUT S - 02/27/2003
SANITARY N0. CONTROL NO,
ARCHOECDENGINEER: BUILDING PERMIT INFO
BO EO PLUMB -0
�00 - LICENSED CONTRACTOR'S DECLARATION Job Description
+O 1 hereby af0rm O0SC1'I that I am licensed under pro of Chapter 9 cnmmcneln{ P
With
Section]QMgtfD Sof the Businea Profeuinn,Codc,e my llanm is ,.
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fW.4 Dau Con TI--REPLACE POST
y'b FINAL
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Lic
'� 1 n n my am atollMuredo bIk ." '
3; Professionalen edProfessionalMAR'0 6 2003
OWNER-BUIIJ)ER DECLARATION
N I hereby aBtrm Net I em exempt from the Comtanoh License Law for the
y00 following moson.(Secsar 70313,Business and Profesdum Cade:Any city or aunty BUILDING
$9 which requtms a permit to construct,slur,improve,demolish,no repair any anucwm
fzm prior to its issuance,also requires the applicant for such permit to file signed statement
gig <
that M is licensed forward mthe provisions ofthe CmuracufSLtamciaw(Chapw9 Sq.Ft. Floor Area WZon
$ (commercial with Section 70(10)of Division 3 of the Business end Professions Code)or
Nat he Is exempt Nertfrw^and the basis for at alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of r - Occupancy Type
not more than raw hundred dollars(8500).
Cl I,as owner of the propeny,armycmployees with wage ai their mle eompenutlon,
will do tie work,and the 9tomus Is not intended or offered for ole(Sec.70th,Business UITed Inspections
ori Pro(ndmns Cade:11,,Contractor's License law docs not apply m m owner of 102 — PIERS a q P -
propertywhobuild,or improves thereon,and who doesauhworkhimselfortprou{hhis lO3 — LTFER
own employees,provided that such Impmvemmu am not Intended oroffated for sale.If.
however,the building or lmpmvement Is sold within one year of completion.the owner. 104 — REBAR
builder will have the burden of proving that M did not bund lir improve for purpme of 105' ANCHOR BOLTS
01,as owner of the property,am exclusively tonsuring with licensed consacmn to 106 — SEWER & WATER
eanswm the project(Sew 7004,Business and Profession Code:)lbe Comracmb U.
ane law don nm appy to an owner of pmpeny who wnda^r improves thereon.and, 202 — UNDERFLOOR PLUMBING
who concocts for such projects with aeonmcmr(s)licensed pursuant to Me Contracmla
License law, 203 - UNDERFLOOR' MECHANICAL
., I
exempt under See ,BAsPCfor this reason 204 - .UNDERFLOOR FRAME
Dam 205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION _ 301 — ROUGH PLUMBING
I hereby afn=under penalty of perjury one of the following declarations: 302 TUB & OR SHOWER
ve and will mammin a Cenirate ofCmnsem m selpiusum for Wmrlmes Coat 303' — ROUGH MECHANICAL
'soon,u provided for by Section 3700 of the labor Cade,for tie performance of IM
for which this permit is issued. 304- ROUGH ELECTRICAL
ve and will maintain Workers Compensation Insurance,m required by Section 305 _. FRAME
f me Labm code.sur On parfamsccaf the wmrk for which this pcnmBtsaued. 30 - HOLDOWNS .
times ,(tont wr artier end Policy her are: Y
an at No.; 307 INSULATION'
CERTIFICATE OF EXEMm AN"rROM KER 308 - SHEETROCK
COMPENSA INSURANCE -
711,15 section need not be eompleudif the permit Is forma,hundred dollars is Iwo 309 - EXTERIOR LATH '
micas) 310 INTERIOR LATH -
I aNfy that in Bre penfnrmance of th work for which this permit Is issued.I Nall not 311 SCRATCH COAT
employ any person In my manner an As to Mame subject In Me Workers'Compenatlon 313 — ROOF NAIL
Laws of California.Dam -
Applicant
NOTICE TO APPLICANT,If.after making this CcrtlOcam of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become subject o the Weaker's Corepewtim provision of the Lahr Code,you most SO2 — FINAL PLUMBING ENERGY
,Z forthwith Sa
with comply with such provoor this permit ll he deemed rented.
00 503 - FINAL MECHANICAL ENERGY
CONSTRUCTION LENDING AGENCY 504 - .FINAL BUILDING ENERGY
(••i lamby storm ren Mo.T U TIONLE DINGiA .gancyENCY for Me perfurmatue of
C� the work for which this Permit is issued(Sm.3097,Civ.C.) 505 - FINAL ELECTRICAL
W Q Undoes None
codas Add., 506. - GAS TEST
U oI 1 canlfy mat 1 have read this Application end sww that the she.mfmmmmn I, 507 FINAL PLUMBING
correct.l agree to comply with all city and county ordinances and esu law,mining to
OU buildingcoosuctlon,endherebyauthorizerepre,enutivaorthlauitytoenterupontlw - FINAL MECHANICAL
W aM1ove-mentioned property for inspection purposes. O FIWN
LL (Wc)agree l ve,indemnify and keep harmless tie City or Cupertino against
ti h Ilabilitles.a Agrees ,c umtlexa y which may in any way Aare,spino old Chy O IvlacenlCANT of ES STANDS AIN ILLCOMPLV WI ALLN N•P 5ORKS
L7 l UL Issued by: Date
Re-roofs
SI urto ppiicmVCmnuacmr Palo
HAZARDOUS MATERIALS OISCLOSU Type of Roof '
the applicant or future Wilding occupant scone or andlc hoardoa material
lied by the CupertiKfto
ipal Cade,chapter 9,12.and Me Health and Safety
Sectio zss3z(.)] All roofs shall be inspected prior to any roofing material being installed.
❑Yc, m
Will the applicantbuilding occupant use equipment or devices which If'a roof is installed without first obtaining an inspection,I agree to remove
axardnus air anis an as darned by the Bay Area Air Quality Mmegemenl all new materials for inspection. -
❑Yea Nu
I"Wmedthe n nus materials mquimmcnu under hapurb.95ofthcCalifm-
ntaHeal1&SafmyC c, Wil25505,25533ond25534.Iun umd etlfthe ilding
d currently he heart,that B Is At tea 'hility to no t up of de
mq w hm be t toigs aofaCenine, 9Signature of Applicant Date
net m umoradagent pp V73 All roof coverings to be Class"B"or better