02100116 CITY OF,CUPERTINOBUILDING DIVISION PERMMTCON. RACTURI�NF®RMATON:.
BUILDING ADDRESS: WATTb UUN6TRUCTIUN PERMIT NO.
22820 SAN JUAN RD 02100116
-R'SNAME: 3941 RINCON. AVE PERMITIESUEDATE
,IOM HUTTON 02/25/2003
PHONE: SANITARY NO. CONTROL NO,
ARCHRECiIENGINEER: BUILDING PERMU INTO
9O D PLUMB
MECH
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�Yoo LICENSED CONTRACTORS DECLARATION Job Description<� I hereby.(hire that I am licensed under prevision of Chapter 9(commencing p
with Section 7")of DMA.ut aur the Bus(nna Nucleation Coxim. nd my O,.nm I,
'a Ifmunrecande [.[i GARAGE ADDITION (286 SQ. FT.�B� ��®
S t�e 3 Llccnm 1 Lk.g �s0 `�
Z Dau Comraemr
•0e ARCHI;;;S DEC ON
_y 1 understand my plana Nail be used as pu)ilic raoN.
;bnedproksin
sna, MAY 2 0 2003
r� Lia
OWNER.BUILDERDECLARATION
j�q I hereby affiro (sm that I am exempt from the Contractors License Law for the BUILDING
o D following mon. ection 1031.5.Buganda and Profession Code:Any city or county
$E! which mqulrea a permit m convect,slur.Improve,demolish,at repair any structure
h,�Se prior to W issuance,also requires the applicant for such permit to File asigned statement
zFFp lost he is licensed[unuanun the provision of the Contractor's License Law(Chapter 9 _ Sq.Ft.Floor Area 2 Mlillgion
3a (commencing with Section 70)(0) DNiskn 3oftho Business and Prorusalous Csxle)or
3 that he la exempt therefrom and the bu4 for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant m.civil penalty of
not more Nan fin hundred dollars($50Mh eT - Occupancy Type'
❑1,as owner or Ne property,or my employee,with wages as their ma compensation, 101
will do the.,Land the ametun Isnot intended reoffered letters(See.7044,Business
and Profession Cone:The Cornerstones Liaox Law don not apply in an ower of 102 - PIERS Required Inspections
prepertYwhO buildaor(mproes d¢reon,and who doessuch work himselfor through his p03 .—UF,ER_—
own employees,provided that such improvements an not intended oraRend for sale.If, -
however,Ne building or improvement is mid within an yearofcompledon,use owner. 104 REBAR
builder will have me burden of pruving mal he did not bold m improve for purpose of 105 , - ANCHOR BOLTS
ukJ.
01,as owner of the property,am exclusively contracting with licensed commtera to 106 - SEWER & WATER
construct the project(Sec.7D44,Business and Profession Code:)The Contractors U. '
come law does net apply to an miner of property who builds or lmprom human,and, 202 - UNDERFLOOR PLUMBING
who contracts for such projects with a eomucor(0 licensed pursuant to the Contractors 203 - UNDERFLOOR MECHANICAL
License law. -
❑lem.m.N.ndersee. ,B&PCfurthimage 204 - UNDERFLOOR FRAME
Dam 205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION '301 - ROUGH PLUMBING
I hereby affirm under penalty of perjury one of the following deelarnionr 302 - TUB & OR . SHOWER
❑]haw and will maintain aCerificateorcommnttomlr-lnummrworloceCompen- 303 ' -. ROUGH MECHANICAL
utlon,u provided for by Smtlon 3700of the labor Code.far din perhomence tef the
work kr which dila permit it issued. 304 - ROUGH ELECTRICAL
❑1 have end will maintain Weaker'Compensation Insurance,as required by Section 305 - .FRAME
37M of the labor Code,for the performance of the work for which this permit Is issued.
My Wark��wy.,�'ampenWon insurance tartlet end Pol' umber are: ��.�� 306 - HOEDOWNS
Cotler• \ '�!`_ �� Po11ey�5]� 307 - INSULATIONS
CERTIFlC OMPENSAON NSUFRANCEORKERS' 308 - SHEETROCK
(This rccltm need not he completed if the permit Is forest hundred dnllm 1$1M) 309 - EXTERIOR LATH
mine.) 310 INTERIOR .LATH
1 mugry lost in the Performance of the work for which this permit Is issued,I shall not 311 SCRATCH COAT
employ any person in my manner an u to become to the Workers'Compensation - -
Iawanfcalimmla.Dsm 313 - ROOF NAIL
Applicant
NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become uhjectu the Worker.Compensation provision of the lahm Cost.you most 502 - - FINAL PLUMBING ENERGY
zOforthwith comply with such prevision or this permit shall W deemed ranked. 503 - FINAL MECHANICAL ENERGY
CONSTRUCTION LENDING AGENCY
[..rr Ihereby afMmthatthem laaconstruction lending.gencyfar theperfurrommof 504 - - -FINAL BUILDING ENERGY
$S� the work for which Oil$Permit laissued(Sm.3097,Civ.C.)
Lender'.Name 505 - FINAL ELECTRICAL
f$d Q
Lenders Addmn 506 , - .GAS TEST'' _
U O 1 anify that 1 have rad this application and must that the above information is 507 - FINAL PLUMBING
ty F correct,l agrce to comply with all city and county ominanm and most laws rel.tingw 8 _ FINAL' MECHANICAL
building construction,ad knotty authorlas refuarowi s of this city to enter upon are
lUU above-mentioned property for Inspection purposes. 0 - F I L GRADE
(we)agree re sive,indemnify and kap humins the City of Cupertino against
r-i II,) Ila ailments,ensu end expence which may to my my accnm against old City O FI PNG
Ui PPLnICw-T of ERSTA gDSrtfIA1ND WILL COMPLY WITH ALL NON-POINT Issued by: 5 'WORKSDat6
URGE REG TI Ns.
_ Re-roofs
gnmu or"Pli HAZARDOUS MATERIALS DISCLOSURE - Dete 'type of Roof"
Will the applicant or future building occupant a tom orhandlc huardoe,material •7
a Med by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
See on 25531(a)7 J All roofs shall be inspected prior to any roofing material being installed,
❑Yu Mf"
Will the applicant or future wilding=.Paul use equipment m deviaa which If a roof is installed without first obtaining an inspection,I agree to remove
colt haraNnus allconuminants u d Mod by the Bay Ana Air Quality Management all new materials for inspection.
District?
Owe
I he.mad the h.sardous maurlais,requirements under Chapter 6.95 of the Califor.
nia Heulm&S coYCodc,Sation15505.25533md25534.1undcmwdthmlf0ubullding
J48c,
not cu n y haw a racer Net it Is my rusponsihiliry m ratify`c acupant of the
mmu hmuu melprior to iuuana life Cenifmau ofR upan Signature of Applicant Date
OnuthorbedAgent D,ma All roof coverings to be Class"B"or better