02100063 (2) CI'T'Y OF CUPEWFINO
BUILDING DIVISION PERMITGONfRAC^,°TTOR INEORMTION
Bulfp16*11RESTULA CT WM H FRY CONSTRUCTION COMI FtRY N02100063
QwIA31RAMA MARK 10351 SAN FERNANDO AVE APPLICATTI0SYRPB'Y2002
A,
liploved Wo_8T 996-8173 SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMpp INTO
BLDG ELECT PLUMB MECH
O O O O
xw00 LICENSED CONTRACTOR'S DECLARATION ,-,I Lty�.]��$ ppt�
m P I hereby affirm that 1 em IiccaxJ under provisions of Chapter 9 faontmcndng REPLACE SHOWERIyNG W C V
<� with Section' Mnnf Division Sof Ne Busi and Professions Ctale.under,icenxis w C®
< in lull line deffca. /'1►7`aN+
��� I.icenx C ass I.ii�N
04—O Date \o sg .. Co uun�.okr.AWAh U FP
gF� tun rst Jay planRC„11' CT as l7tlMfc rcc+a� JUN 1 0 2003
'yo6u L c
3p� Licc;...
t cions( '14G
OW am exempt f DECLARATION
oil rc <p by affirm that am exempt tram the Contractor's License live for ohc
ti 600 fulls (Section 7031.5.Business and Professions Code:Any city or county
$� whits a pcsmit to elmselnn,alae improve,demolish,In repair any.(,act..
prior ht its issuance,also"does the applicant for such permit to file a signed statement '7t/�,��p
p�px�x< that he is licensed pursuant a Ne provisions of the Cormwtor's License lata,(Chapter9 913 xaefa Alai) Valuation
CFO (commncing with Section 70X0.(Division 3 of the Business and Professions Cock)or
y that he
e is exempt there(,..and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of i UAPNN Occupancy Type
not mom than five hundred dollars D50). 102 - PIERS p y yp
❑ I,as owner of the property,or my employees with wages ss their sole compensation,
will Jo the work,and the sunned.is not intended or offered for sale(Sec.7W,Business
and Professions coda:The Contractors License law does nor apply,o an owner of 104 — REBAR Required Inspections
property who builds or improve thamon,and whodecrouch work himself or through his
own employee,provided that such impmwmenm are no,intended oraffecd for one,IL 105 — ANCHOR BOLTS
however.the building orimprovement is sold within one year o(comple,ion,the owner- 106 — SEWER & WATER
builder will have the burden of proving that he did not Wild or improve for purpose of
.Jr.). 202 - UNDERFLOOR PLUMBING
01.as owner ofthe property,am exclusively contracting with licensed convectors to 203 - UNDERFLOOR MECHANICAL
construct the project(Sec.7(Hm,Business and Professions Code:)The Contractor's I.I.
cross 204 - UNDERFLOOR FRAME
who such limiters with anmoem.(s)licensed pursuenu.the Cnmmmm'nm ,Law. 205 - UNDERFLOOR INSULATION
❑ I am exempt under Sec. .B III PC for this reason 301 - ROUGH PLUMBING
owner Data 302 - TUB & OR SHOWER
WORKER'S COMPENSATION DECLARATION 303 - ROUGH MECHANICAL
I hereby afetm anger panahy of perjury one of the following declarations: 304 — ROUGH ELECTRICAL
I have and will maintain a Cenificae of Consent o selfmorm for Workcr's Compete
cation,or provided for by Section 370()of the Libor Code.for the performance of the 3 05 — FRAME
work for which this Permit is issued. 306 - HOLDOWNS
El 1 have and will maintain Worker's Compensation Insurance,as required by Section 3 07 - INSULATION
3701 of the Labor Code,for the performance of the work for which this permit is issued.
"(Worker's CCompenstionln ncccan�nePuticynomberam: 308 — SHEETROCK
cTMter: �r�kvcr.+ P.I .: sL!�,_ zz'i 309 - EXTERIOR LATH
CERTIFICATE OF EXEMPTOM WORKERS'
COMPENSATION INSURANCE 310 - INTERIOR LATH
(This section need not Mcomplemdifthe permi,isforone hundrcdd.11ars(S10) 311 - SCRATCH COAT
tale") 313 - ROOF NAIL
1 aenify that in the performance of the work for which this Permit is issued.(shall not 501 - FINAL ELECTRI CAL ENERGY
employ any a rm n in any mannerso assn become subject to the Workem'Compensation
Lows of California.Date 502 - FINAL PLUMBING ENERGY
Applicant
NOTICE TO APPLICANT;ll;alter making this Certilicae of Exemption.you Audi] 503 - FINAL MECHANICAL ENERGY
become subject m the Worker's Cone oration pmvinoosef the Libor Code,you..at 504 - FINAL BUILDING ENERGY
OO forthwith comply with such provisions tit this permit shall he deemed mvoked.
z CONSTRUCTION LENDING AGENCY
505 - FINAL ELECTRICAL
PwV1+ Ihcmhyallinas .'Or.isaconsuuction lending.,ri,fnnhe pennion.ma of 506 - GAS TEST
a ?
the wnkfill which do permit isissued(Sce.30)7.Civ.C.)
lindc507 - FINAL PLUMBING
W Q fi Name
a z tinder's Add.. 508 - FINAL MECHANICAL
LJ o 1 certify that I have read this application and some that the show information is 509 - FINAL GRADE
lyU buildingcorectaen,andhrebyah all ityandmm�tynativescsanJsmmiswtrelsdngto 5 FINAL PLANNING
correct.cat nee to o comply
ly hereby a city
and aunty onfiram of andcity a enter upon the
y above-meminned property for inspection proposes.
{ a (We)agree In save,indemni and keep harrnleas the City of Cupertino against 14 FIN BII I W RKS
t^ y Iiehilitics,juJgments,costa and ex sea which may in any way aaruc against wiJ City
U z mntnxyucoc of the graining of is mit.
APPI.ICA UNDERSTAND A WILL COMPLY WITH ALL NON POINT Issued by: Date
SOUR :GULATION -
t� Re-roofs
to, .f Appfiaan✓Co
Htar m
AZ DOUS MATERIALS DISCLOSURE. Type of Roof
Will the applicant a future building occupant store or handle hamNoos material
linml by the C.,Promn/�'t/y Mugi'put Code Chapter 9.12,and the IRoth and Safety
c.�tea 2531z(a)?
YAll roofs shall be inspected prior to any roofing material being installed.
Will the ti,licanuo fuerc building ov...to due mbipmein o,devices which If a'roof is installed without first obtaining an inspection,I agree to remove
mat hawrdous air cmurm mmin sex defined by the Bay Arca Air Quality Management all new materials for inspection.
Disticfl
❑Ycs A.
I have Jthc hasard smatQalsmyuircmentsundcrChapmr695oftheCalifnr-
nisllealthdeb coy Ccw.Sc .2 15,25533.dM531.1unJer.d"iftMbuilding
does not 6 ndy narc a t t, it is my respmsihility m notify the tccupmt of de
rcyui cat whichom me t .I:,mZmaceofaCcnifi mar aney. Signature of Applicant Date
aa.th.iaed em nee All roof coverings to be Class"B" or better