03070213 (2) CITY Of CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMAT'l ;
B UILDINC ADDRESS: SUITABLE CONSTRUCTION PERMIT NO03070213
o
:R'S NAME: 18915 DEVON AVE PERMIT ISSUE DATE
PHONE: (408) 370-7120 SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
10p
LICENSED CONTRACTOR'S DECLARATION Ib Description
1 hereby ef0rm Nm Iimn
I am uJ under provisions of Chapter 9( mOescrIP
encing
aa with Section 70IID)t ivisi of Jm nusineu and Pfpfcssiuna Code.end mylicenu is
°<d in fullrnreean cr 1. �_—Ss39/7 REVISION--IN HOUSE USE ONLY
j Z Lima- L .
Data Cuntraamr NO NEW PERMIT ISSUED ORIG. #03030074
ARCI ITELTS OECLARAT
fIFO1 ammor anJ my plans shall he wail as puhli
so
Licensed Pmfcuianel
OWNER-BUILDER DECLARATION
<I 1 hereby of irm that I am exempt from Ne Contractor's License Law for the
D O following maxame.sui on 703 IS.Business and Professions Code:Any city or county V
e Si which requires a permit in CoMINcl,allot.improve.demolish,or repair any structure
�z i
that
ann ire tensed pursuant
r us regoinv Ne apimes of far Co pe tar's Ne se Laved ammmem
E < that heincingwJpunuaanatheofDivinmofthe ofthe0uhawandPhirlaw(CNPWrY Sq. F[. Floor Area Valua[io,�lO7
d 0 (cot he I,exempt therefrom
andtfOivisiofr of theegedasamdor,Aninne CMc)ar
� $ Nei he Is exempt themfmm end the baa for the alleged exemption,Any=of an
Section 7031.5 by any applicant for a pennh subjects the applicant to a civil penahy of 3471Sf8Qi1crO O Occupancy Type
not more thanfinhundred donam(SSW). P Y YP
❑1,u owner of the prvpeny,er my emplayca with wega ss Neinole compeneallon,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Comreclor's License Law does not apply W in owner of 101 - FOUNDATION gInspections
property who builds or improves Merron,end whoppers such work himself or through his
own employces,provided that such improvements ve not intended oraRered forule.If, 102 — PIERS
however,she building or improvement is sold within one yev of completion,the owner.
builder will have the burden approving that he did not build or improve for purpose of 103 — UFER
ale.l. 104 - REBAR
0 I.as owner of the property,am eaclusively contracting with licensed ronbulo s to
construct the project(Sec.7044.Business and Profession Code:)The Caroni Li. 105 — ANCHOR BOLTS
ceme law does not apply to an owner of property who builds or improves Nemon,and, 106 — SEWER & WATER
who contracts for such projects with a conlmcm hi)licensed pursuant to Ne Contaaors
Lbenselaw. 202 - UNDERFLOOR PLUMBING
eaempluader Sm. ,B&PCfor Nis moon 203 - UNDERFLOOR MECHANICAL
MIFF Data 204 - UNDERFLOOR FRAME
WORKER'S COMPENSATION DECLARATION
hereby alnrmuOder penaltyorprj.,me,ofOr,following deeluallons: 205 - UNDERFLOOR INSULATION
❑I hoe and will maintain a Certificate of Consent o relf.insum for worker's Compere 301 — ROUGH PLUMBING
talion,u proviecd(m by Section 37M of the Labor,Code,for the performantt of the 3 02 — TUB & OR SHOWER
work for which Nis permit is issued.
❑1 have and will maintain Worker's Compmastion Insurance,as required by Section 3 03 - ROUGH MECHANICAL
37M INe Labor Code,for the pedaammce of the work for which this permit is located. 304 — ROUGH ELECTRICAL
My Workers Compensation Insurance artier and Poli cram: 305 — FRAME
CERTIFICATE OF EXEMPTION FROM WORK ERS' 306 — HOLDOWNS
COMPENSATION INSURANCE 307 - INSULATION
(This au
his not In completed if the Permit is for one hundred dollars(S 100) 308 — SHEETROCK
or Rac7 309 - EXTERIOR, LATH
I cenify Natt or she rformance of thew rk for wIF his permit is issued,l shtll not
LaweofCilifo"n". e6y mann pit �ee ao tWWorkeri Compenaetlon 310 — INTERIOR LATH
Aw'on 311 - SCRATCH COAT
N071y�y��4�.A'�PLICANT:If,after making l e, e rricam of Exemption,you should 313 - ROOF NAIL
McoME mhjcn to Nc Workers Compensation previsions of the labor Calc,you muss
� ,Z forthwith comply with such provisions or this perm it shall he deemed revoked. 501 — FINAL ELECTRICAL ENERGY
Z0 CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
Iherehyalfirmthst thersuacoawnion lending agency for the Performance of 503 - FINAL MECHANICAL ENERGY
Y' 7 me work for which this pennil is issued(Sec.W.Civ.C.)
:f3p Lenders Name 504 - FINAL BUILDING ENERGY
=)zanaersAadma 505 - FINAL ELECTRICAL
J p 1 cenify that I have read Nis application and sum that the above information is 506 - GAS TEST
Fcoven,l agree to Comply with all city and county on inaWes and slate laws relating to
.Lr
building convection,and hereby authorize representatives of this city to enmrupnn the FINAjj PLUMBI G
�6UWi above-mentioned properly for inspection purposes.
(We)agree to aces indemnify and tech may
in m w City of Cupenino against A08aFIjg�AL
liabililiWe)grema,case,endupcaad liici momel anywayey of CulainsaaidCityinst 5
z IAnPPLCAeNT U the gronling of lhisO W l PLY WI ALL NO POINT Issued by;5 Dat
ULATIONS,
/ Re-roofs
arc of App scmVComrutor
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant OF future building acupam nam or bandit.huition,mnerial
as deOncd by me Cupertino Municipal Code,Chapwr 9.12,and the Heahh and Safely
01Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Ya �Ni
Will the applicantoo'r`futurebuildi�ngOccupantuse equipment ordevices which If a roof is installed without first obtaining an inspection,I agree to remove
emit harardous air contaminants IF defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes
I have read the harardnus materials mquimmants under Chapter 6.95 of the Califor-
his Deal thdSaheyCode,Secures;25515,25533 and 25534.1 understand that ifum building
does not currently have a foam,that it is my responsibility,in nnul'y the Occup rut of the
reyuirtm tbcmctpdorwissumceofaC of cup Signature of Applicant Date
r or aulhadred egcnl Dim,
All roof coverings to be Class "B" or better
CITY OF CUPERTINO '+ �:4xs � +""''
BUILDING DIVISION PERMIT =^SC� RQR TNFOT.tMA.TIQN
EP'FP9geD?3T.CAMORE DR. SUITABLE CONSTRUCTION PERMITNO
t
EGALIOTTO 18915 DEVON AVE P°""tTTj"29/2003
NE (4 0 8) 3 7 0-712 0 SANITARY N0. CONTROL N0.
ARCHITECVEHGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�oZZ, LICENSED CONTRACTOR'S DECLARATION Job Descri n00
I hereby afOrm Net 1 em Ileeosed under provisions of Chapter 9(Commencing P .7--O lass\11 ,p A
wIMSection 7")of DMdon 3 of Ne Boalecssand Profesdmu Cm e.md my Ilan.is 11`J Gse(a
''a� in fullfortt and erten. ADD 367 SQ.FT.
j�Z License ClassLk.0
Dass ContractorDECLARATION
SEP 2 2
ARCHITECTS DECLARATION 003
I undersand my pans m.li Musa)as public mixtrds
a Licensed Professional
OWNER-BUILDER DECLARATION BUIL®hvG�
1 hereby af0rm Nal I am exempt from Ne Contractor)License Lew for the
❑O following moon.(Section En I.5,Business and Professions Cade:Any city or county
$ which requires a Permit to Convect allot Improve.Mmops,at repair any swan¢
HZ� prim m is issuance.sim ontomt the applicant far such permit to rile a signed summem
ggg G that Wislicensed pursuant todcprovisions ofthe Convector'sLlemse Law(Chapter 9 Sq.Ft.Floor Area $140��®tion
$ — (commencing with Section 7000)of Division Of the Business and Profession,Coic)or
du Nat he 1,exempt therefrom and the basis far the alleged consumption.Any violation of
Section 7031.5 by any applicant for a permluubjects the applicant to a civil Finally of 3 412'9IINIt"er 0 0 Occupancy Type
not more Nan In hundred dollars($500).
❑i,uownu of the Propmy,mmy cmploycn with vngcaadtebmle campcwdw,
willdo Ne woh,end Neatruclurt is wt intended m oRcred Torula(Sec.]ON,Bwi-As
Nd Prof46NN Code:The Canaaclara License tAw chess Pat apply to a.aWlla,of 102 - PIERS d Inspections
property who Wil ds m im prow.the......d who doeu-h work hi msel f or througb his
ownemplOyeca,provided Munch improvements and not intended.,.Road forule If. 103 — LIFER
however,the building or improvement is mid within one year of Completion,Ne Owner.
W oder will hem the burden of proving Nn he did not build or Improve for purpose of 104 — REBAR
a"')' 105 - ANCHOR BOLTS
❑1, a Owner of the property.am exclusively contracting with licensed contraemrt to
construct the project(Sec.70".Bu,lness and Profession,Code:)The Contractor's Li. 106 — SEWER & WATER
terve Law does not apply to an owner of properly who Wilds or implant Marmon,and 2O2 — UNDERFLOOR PLUMBING
who contracts for such projects with a eontracmr(G licensed pursuant to the ConvacloM1
License law. 203 - UNDERFLOOR MECHANICAL
❑I em ea�ry..dn sec .B&Per,sits reams 204 - UNDERFLOOR FRAME
'1 �4L:) .baa 03 205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATION DEC TION
IWreby effort under penalty ofitchry arc of the fallowing declaatiuns: 301 - ROUGH PLUMBING -
IhamandwillmaintansCenlficaa of Lament to self-hilum forwortehcompm. 302 — TUB & OR SHOWER
sation,as provided for by Section 37M of Ne labor Cade.for Ne performance of the 303 - ROUGH MECHANICAL
work for whim this Permit IS issued. 304 - ROUGH ELECTRICAL
❑I ban and will maintain Worker's Compensation Insurance,as required by Scedon
3700.fthe LPWrcodc.far the performance arthe work for which Ni,permit is issued. 305 — FRAME
My Workers Compensation Insurance carrier and Policy number art: 306 — HOLDOWNS
carriee Policy No.: 307 - INSULATION
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 308 — SHEETROCK .
(Thb sectim need amocompleted Hilo,lcrmlt is fntonc hundred dollea(SIM) 309 - EXTERIOR LATH
cu`l`t`) 310 - INTERIOR LATH
I-Airy Nit in the performance of Ne work far which this parmh Is issued,10411 not'
employ any M,rao my manner u omesubjecuothiWaken'Compensalmn 311 — SCRATCH COAT
Lewtof Calif a. 313 - ROOF NAIL
,Applicant
N CETT PPLI NT:If,after making this CetiftcaaofExemption,you should 501 - FINAL- ELECTRICAL ENERGY
me subject to tbe Workers Compensation provisions of the Lahr Code.you am
�o .Mwkecomply with mtslm
ehprorsorthispermitshenWdcemadrevoked. 502 - FINAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
F 1 hereby kforwhichtmNermeretsaco (Sec.3 lending agency l'nrthe parfmmanceuf SO4 — FINAL BUILDING ENERGY
U i> th,work for which this permit b issued(Sec.7097,Co.Civ.CJ
Q p Lattice, 505 505 - FINAL ELECTRICAL
.7Z tneef,Addma 506 - GAS TEST
U0 1 certify that 1 lave read this application and Sate that sic above Information IS 507 - FINAL PLUMBING
It E correct.1 agree to comply with all city and county ordinances and ma Iowa mledng to
p VC Wilding construction.and hereby mN.rlm mpaaentedru or this city be closer upon the FINA MECHAN CAL
W shove-mentioned property for Wpection purposes.
(We)agree to U.,indemnify and keep harmless the City of Caperton against 0 9 F I N GoAng
y liabilities,judgments,costs and expenses which may in my way a cam against aid City 5 A, G
U 7 In consequence of the grand,of this Fermit. �.
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by 5 WORKS Date
SOU ED AA TI---I��ONS.
ore �G`/ 4Re-roofs
stare of nnHAZARDO arc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will y t applicant l m(Muni ipal Cg occupant nom-bandie Healthrodhur and Sterial
afety "
a derine0 by the Cupertino Municipal Code.Chepar 9.12,and the HceIN and Safety '
ode.Section 3553207 All roofs shall be inspected prior to any roofing material being installed.
❑Yes �No ''
Will IW applicant.,future building occupant all,equipment or device,which If a roof is installed without first obtaining an inspection,I agree to remove
emit tantrums air-naminmts as defined by the Bey Ar-Air Quality Management all new materials for inspection.
District?
❑Yea �Nu
I have read a
the IuNous materials requirements underCMpin 6.95 of the Califor.
nia Health&Safety Code,Sections 75505.25533 and 25534.1 rte@rsaM Nu If sic Wilding
U.not currently hem a tenant.Net It u my nexponsihihty a-ofy the aec.,.I of the
raquimore which mtWmm 1M
IP. I.issuance or.comrra IOccupanry Signature of Applicant Date
rte,a sulloatilfccl.gum barn All roof coverings to be Class"B"or better