02060088-FP CITY OF CUPERTINO 7p��RAC
BUILDING DIVISION PERMIT MIT CO#V: TOR IN'FORMA7r�I. o
BUI AD&E@LANEY AV K & M DEVELOPMENT INC PERMIT 10.2 0 6 0 0 8 8
owRUU4&EC CHOU 1060 WEST HILL CT APPLICATEP6SPIIQ4'f)t2002
PHONE: (408) 253-9787 SANITARY NO. / CONTROL NO.
ARCH ITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
w O O LICENSED CONTRACTOR'S DECLARATION
FLu 1 hereby affirm that I am licensed un�r provisions of Chapter 9(commencinge�Cc��pp
U U with Section 7000)aDivision 3 of the Bus(pf ad Professions Cod,and my license NEW SINGLE F iJW`�LL I NG
Fey InmBebme Qdfrfcct ✓/' �� LIVING SPACE 2609 SQ.FT
Z p v�Z License CI�.s�`' Lic.N
sz—o Date c t ewr r- 1 IrC GARAGE 431 SQ.FT. /PORCH 39 SQ.FT.
1-!2 t- ARCHITE ARATION
o V I understand m plans shall he used as public records
a
ski 3 u.t— Licensed Professional
U.
y OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
LU 00 following reason.(Section 7031.5.Business and Professions Code:Any city or county
which requires a permit to construct,alter,improve,demolish,or repair any structure
Z prior to its issuance,also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area $3 0 0&110ation
!_—p (commencing with Section 7000)of pivision 3 of the Business and Professions Code)or
y that he is exempt therefrom and dre%a_sis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars($500). b Occupancy Type
❑1,as owner of the property,or my employees with wages as their sole compensation, Febw
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of10 2 — PIERS equlred Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If, 103 — UFER
however,the building or improvement is sold within one year of completion,the owner- 104 — REBAR
builder will have the burden of proving that he did not build or improve for purpose of
sale.). 105 - ANCHOR BOLTS
❑1,as owner of the property,am exclusively contracting with licensed contractors to 10 6 — SEWER & WATER
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and 202 — UNDERFLOOR PLUMBING
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law. 203 — UNDERFLOOR MECHANICAL
❑1 am exempt under Sec. B&P C for this reason 204 — UNDERFLOOR FRAME
Owner Date 205 — UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION 301 — ROUGH PLUMBING
1 hereby alum under penalty of perjury one of the following declarations: 302 — TUB & OR SHOWER
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation, 303 as provided for by Section 3700 of the Labor Code,for due performance of the
work for which this permit is issued. 304 — ROUGH ELECTRICAL
❑1 have nd will maintain Worker's Compensation Insurance,as required by Section 305 — FRAME
3700 of th Labor Code,far the performance of the work for which this permit is issued.
My wor is Cam nsation Insurance cam a d Po icy number are- 306 — HOLDOWNS
fJ Z ?_�� /513& 307 — INSULATION
Carrie. No.:
�itrf /It ,I�F]OMP ENSATIO INSURANCE RK ERs 308 - SHEETROCK
Rhisae teConne�notbecompletedifthe permitisfor onehundreddollars(S100) 309 — EXTERIOR LATH
"`less.) 310 — INTERIOR LATH
1 certify that in the performance of the work for which this permit is issued,I shall not 311 — SCRATCH COAT
employ any person in any mannerso as it)become subject to the Workers'Compensation
Laws of Cal ifomia.Date 313 — ROOF NAIL
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become subject to the Worker's Compensation provisions of the Labor Code,you must 502 - FINAL PLUMBING ENERGY
ZZO forthwith comply with such provisions or this permit shall be deemed revoked. 503 — F I NAL MECHANICAL ENERGY
� CONSTRUCTION LENDING AGENCY
t— 1 hereby affirm that there is a construction lending agency for the performance of 504 — F I NAL BUILDING ENERGY
Ix > the work for which this permit is issued(Sec.3097.Civ.C.) 505 — F I NAL ELECTRICAL
W Q Lender's Name
a+ Lender's Address 506 — GAS TEST
Up 1 certify that I have read this application and state that the above information is 507 - F I NAL PLUMBING
Iy F correct 1 agree to comply with all city and county ordinances and state laws relating to 5%9 —
NAL MECHANICAL
Q building construction,and hereby authorize representatives of this city to enter upon the
U above-mentioned property for inspection purposes. 5N DE(We)agree to save,indemnify and keep harmless the City of Cupertino against
c.#) liabilities.ud menus,toss and ex nses which ma to an wa accrues ainstsaid CitU j g th r' r, r g r 5N G �G c>tJ z in consequence of the granting of this permit.APP CANT UNDERSTANDS AND WILL COMPLY WITH AL NON-POINT Issued by5WORKS Date
7ignature
CE REGU ONS. 9
d Re-roofs 6 0 3 — OF BATTENS7
o P HAZARDOr MATERIALS DISCLOSURE Dat Type oflf} — ROOF IN—PROGRESS
Will -applic t or future building occupant store or handle hazardous material
as defined by no Municipal Code,Chapter 9.12,and the Health and Safety
Code, yes 25532(a)?
DAll roofs shall be inspected prior to any roofing material being installed.
Yes �o
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
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes o
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
niaHealth&SafetyCode.Sectiors25505,25533and 25534.1undYtanlatifihe building
docs not currently ha 6 that it s my responsibility to occupant of the
gOwn'Z�r.'
rcmns wht ast be 1prior to iss :c of a Ccrificapancy. Signature of Applicant Date
2� Z
rauthorized nt Date All roof coverings to be Class"B"or better