02100134 (2) CITY OF CUPERTINO & ✓-c§3o�z^s7��, 2� �^� 7xE
BUILDING DIVISION PERMIT y'CONTRACTOR INFORMATION:
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TO,
U 1Lp1ac7,2DRIS4ALLEN CT LOT 5 PERMITNT2100134
SMAME:DEVELOPMENT AP"fcATI1h(J yq' 2002
PI10NIi: SANITARY NO. / 1 / CONTROL NO.
ARCHITEC MNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
upFlpp LICENSED CONTRACTOR'S DECLARATION
F 1 herebyffirm that I am licensed under revisions of Chapter 9 commeMin p�+ Cr
Gz4 with Section7(g)nrDivisiom3llftheBesinessandPmfessionsCode.addmylicenscs ,RE;V1 1ON--IN I-�B PE �� ONLY
<<E in fall to= ORIG. 401100132 , NO NEW PERMIT ISSUED
oZ_Zaw License Class Lic.M
-3 Datc contractor
F.. q ARCHITECT'S DECLARATION
�_'�y� Iundcrsantl my plans.hallbeused as public records [�(—/ (�
%
6p0
LL G Licensed Professional
OWNER BUILDER m DECLARATION \
a1 hereby affirm that 11. exempt from the Contractor's :Any c Law for the
tyu p O whichfollow
mmoa(Section 71onxtr t.alters anti improve.
edo li h,Or:My city or county
a�$ which requires a permit n+conaruct,also,impnsve,demolish.or repair any auucmm J 0
'r+
prior o its issuance,also requires applicant tor such permit file a signed statement
t9?'< mat he is licensed pursuanttotheprevisionsoftheContactorsLicenseLawChapter9 Sq.FL Floo Valuation
1-p (commencing with Section 7000)Of Division of the B usimss and Preficamons Code)Or
�+�$ shat he is exempt themrrom and the has§for the alleged exemption.Any violation of 36218011 . 00
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of APN Number Occupancy Type
not more man five hundred dollars(5500). 101 — FOUNDATION
P Y YP
❑1,as owner i f she property,or my employee.with go,.their ante emapersetion,
will do the work,and me swctum is not intended or offered for aide(Sm.70,14.Business 182 PiERS
and Profusions Code:The Conmctofs License Law does not apply to an owner Of 103 - UFER Required Inspections
urmmny who builds orimprnves mcrcon.and who does such work himulfor through his
own employees.provided thatsuch improvemenesare not intended or offered formic.If. 104 - REBAR
however,the building or improvement is sold within one year of completion.On owner. 1O5 - ANCHOR BOLTS
builder will bars the burden of proving that he did not build or improve for purpose of
"Ie) 106 - SEWER & WATER
El 1,as owner of me property,am exclusively contracting with licensed common to 202 - UNDERFLOOR PLUMBING
construct the project(gee.7044,Business and Projections Code:)The Contractor.Li.
cense law Joos not apply to an owner of property who builds or improves demon,and 203 - UNDERFLOOR MECHANICAL
who contacts for such projects;with a cocoon I.)licensed p....Otm the Contractor.
License Law. 204 — UNDERFLOOR FRAME
❑I am exempt under Seo. ,B&PCfonhiammun 205 - UNDERFLOOR INSULATION
Dare 301 - ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION 302 - TUB & OR SHOWER
I herehy of rm under penally of Perjury no of the following declaasinns: ,303 - ROUGH MECHANICAL
I have and will mainuin aCenificam of Consent to self insure for Workers Compere
ration,u provided For by Section 3700 of the Labor Code.for the perf rmuna of the 304 - ROUGH ELECTRICAL
work for which Nis permit is issued. 305 - FRAME
❑1 have and will maintain Worker's Comperadion Insurance,as myvircd by Section 306 - HOLDOWNS
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number art: 307 - INSULATION .
Camer: PolicyNw: 308 - SHEETROCK
cERTmlcc MPENS rONN'INNSURANCEGRlcens• 309 - EXTERIOR LATH
(This section need not he completed it the Permit is for one hundred dollars u1Nq 310 - INTERIOR LATH
nodeS`) 311 - SCRATCH COAT
I cenify that in the Performance of the work for which this permit is issued.I shall not 313 - ROOF NAIL
employ any person in any manner so ax to become subject to the Worsen'Compensation
Laws of California.Dam 501 - FINAL ELECTRICAL ENERGY
Applicant
NOTICE TO APPLICANT:IL arta making this Ccnilieme of Exemption,you should 502 - FINAL PLUMBING ENERGY
become subject o the Workers Compensation previsions of the Labor Code,you must 503 - FINAL MECHANICAL ENERGY
Z forthwith comply with such prnvisionx or Nis permit shot the derand revoked.
z4 504 — FINAL BUILDING ENERGY
.N. CONSTRUGTIONLENDINGAGENCY
[-+ kforwhaffumNmNcrcisa construction sued( ec.YXG.Ow.Cgcnrylirtthcperformenccof 505 - FINAL ELECTRICAL
Ledu'x forwhichthis perm::is issued(ace.3(Nt,civ.C.) 506 - GAS TEST
Ice Lenin's Name -
I.ereeraAdtlrcm 507 FINAL PLUMBING �1
O
U1certifythat ocIhave readthis
tyandatiunand sumNatmesabove telw,mixingis 508 - FINAL MECHANICAL / ---
0F corm.Iagree tocomply,andherebyath all isyandcounty ounivesesand itytoanterupingm 5 FINAL GRADE
O above-mentioned pro,antl bcrebyanthnrimrcpreunutives of this citymcnur upon the W
above-mentioned property for inspcainn purposes 10 FIN ANN G
(Lac)agree m save,indemnify and keep hay in an the City of Cupertino id City
rZ judgments,costs and expenses mitchmayin any way ammc againstsaid City 5 F N LI WORKS
UZ APPLCANT=UN ERSTANDSgranting Of Ihis AND WILL COMPLY WITH ALL NON-POINT Issued by,t. 60 F NAIL Date 1/
SOURCE REGULATIONS.
Signature of ApplicaRe-roofs 604 - OF IN-PROGRESS
HAZARDOUS
Dale AZARDOIfS MAT,oreti S DISCLOSURE Type Of ROOF
Will the applicant or fMuni building occupant store ser handle hammJomd Safer l
defined by the CuPeninO Municipal Cube.Chapter 9.12.and the licalth and Safety
Pit.Section 255)2(.)? All roofs shall be inspected prior to an roofing material beim Installed.
❑Yes ❑Nn P P Y g g
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
can it humorous air comm insides m defined by she Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes [:J No
Ibuvc read the haerohme materials requirements under Chapter 695 of me Califon
ria HcaIW&Sudety CsvJc.Scninns 255115.255J1 and255J4.1 unJcrsmnJ mm if Jsc building 3, .
does nos curcntly haw a tenam,Nat it is my rcepansihllitym notify the mcupant of the
requiremenu which mum be met prior in isconce Of a Cemficam of occupancy. Signature of Applicant Date
Owner or authorized agent Date All roof coverings to be Class "B"or better