03060039 77�,TY OF CUPERTINO
BUILDING DIVISION PERMIT WCONaCCTURNFORMWP :i -
BU115INGADDRESS: M DUA CONST PERMIT N003 060 03 9
10354 BYRNE AVE .
NER'S NAME: 15 HARTNELL RDpinumiSEOW04/2003
M LIMON
NE: — SANITARY NO. CONTROL NO.
ARCHI'IELT/PNGINEER: BUILDING PERMIT INFO
BLDG ELECTO PLUMB MECH
O
>]oij LICENSED CONTRACTOR'S DECLARATION Job Description
1 booby aam that I am named under provisions of Chapter 9(Commencing
with SaMon70()U) an3of Ma Busin and ofessi.Code.andmylicenseh NEW 'FIREPLACE ''P
:^ in full farts e e
n License Clean v/V
Da Canis
A H17EM D RA
sande rad y phm Mmatl rte used elpen olds /
3 tg Liceme0 Profcuianat S
OatNET-BUILDER DECLARATION 4:5�
1 hresu .(Sect Nal I am exempt from the Cssions o Licenu law for the J
E00 following renmn.(Scion 70711,n,alrcee and ew,emote Code:Any oily or quay
$Pi which uqulua•permit re cores Me altar.nnpmve,demuliN.or repair Signe y structureant
FSS^
prior
miuiuuac0.ahorequiMe lhovisiosofMe,applicant anchpeen's Licerile aatgndmtemem
�t< Nai hchllcansed Purwentrothc provisions of the ConuacuK+Lianse law(Chapter 9 Sq.Ft.Floor Area SQ"[ion
s$ (commencing with Suction 7000)of Division 3 of the Business and Pro,fwinm Cde)w
l�L
that he b exempl ihem(rmn and du brei+for Ina at eumptlon.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of er Occupancy Type
not more than rive hundred dollars($500).
❑I,u owner of the property,o my employcea with widened Meir sole compensation.
willdo the work.and thegme=is aomboadd Mantled fosale(Sec.7ON.Buhels Required Inspections
and Profetaons Code:The Conuumrs IJ.law does Cool apply Wan owner of 102 - PIERS q p
propenywhobuildturimpmve+thereon,andwbo dasasuch wok himselfortbmugh his 103 — UFER
own anplayarg,provided that such Improvements;tie nolinmakd wall"for War IL
however,the building orimpreamenl is sold within one year oreampledoo.the owner- 104 — REBAR
teele�will haw the en burden of proving thhe did ml build an improve for purpose of 105 — ANCHOR BOLTS
1,u owner or the property,am excluaiwly coouse0ng with licensed contractors u 106 — SEWER & WATER
construct the project(Sec.70/u.Business and Professions Cade:)The Convuou's U. 202 — UNDERFLOOR PLUMBING
cause law dean not apply to an owner of property who builds or Improves Nation,and
who contracts for such projects with a conuscmHs)licensed pouuanl to the Conu¢tora 203 - UNDERFLOOR MECHANICAL
License law.
❑lameaemplundasea .BBPCfWddxmkmm 204 - UNDERFLOOR FRAME
Date 205 - UNDERFLOOR INSULATION
WORKERS COMPENSATION DECLARATION 301 - ROUGH PLUMBING
I hereby aalren under pewly of perjury aro of the fellowind dechrmonc 302 — TUB & OR SHOWER
❑I haveaml will mamism.Cenifiaseof Comealuself-imam for Worme.Camper- 303 — ROUGH MECHANICAL
uatirrmi uar wpmv�dMW fohis r bnym5mtit is wanuca 00 of the lobo Code,rat ate performance of Mtn 304 — ROUGH ELECTRICAL
❑I Mn and will maintain Worker's Compensation Insurance,u vanished by Section 305 — FRAME
3700 of the Labor Code.far Mu performance of the work for which this permit is roved. 306 — HOLDOWNS
My Worke1r)�sc-oymL'pensNan�Inutan/a earticr and Poli bar au:
Carger.j[s�3�c�Poliq 307 - INSULATION
CERI7FlCATfi OF BKEMPIION woRKERs• 308 — SHEETROCK
COMPENSATION INSURANCfi
tsaedon reed mibcampleediftie permit4fmaa hundteddalan(5100) 309 - EXTERIOR LATH
mleac) 310 - INTERIOR LATH
1 certify that in the performance of the work for which this penult is ioued.l Nall net 311 - SCRATCH COAT
employ any person in any manmr an as to become anbjeci w Me worken'compcnuuan 313 — ROOF NAIL
Laws of CW forma.Date
Applicant 501 - FINAL ELECTRICAL ENERGY
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become abject to Ne Worker's Compensation provisions of the labor Codc.you mug 502 - FINAL PLUMBING ENERGY
zO forthwith comply with such provisions or this permR+hall W deemed revoked. 503 — FINAL MECHANICAL ENERGY
y CONSTRUCTION LENDING AGENCY 504 - FINAL BUILDING ENERGY
[.. 1 hereby ailing than Caere i+a Conanednn lending agenY,for Me performance of
C> the work for which this permit IsWood(SM.3097.Ch,C.) 505 — FINAL ELECTRICAL
Laftes506 — GAS TEST
z tenders Adding —
U0 I Certify wnot
t 1 ban read this application ami e than the above information is 507 FINAL PLUMBING L
UW !". camect.I ague a comply with an City and county meimanco,and sus ism misting m 50 - FINAL MECHANICAL
0 kSJ^ building comuuction,and hereby sumorim representatives of this City to enter upon Me
R7 above-mentioned properly for Inspection purposes. 0 9 FIN GRADE
N (WC)agree in sen,indemnify and keep harmless the City of Cupertino against
liabilities, 0 F I N
judgments.costs and expenses which may in any way acme against old City
U Z in consequence of the Starting of this PCit. 51 — A WORKS
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N -P01 Issued by: Dat 1
SOUR ULATIONS.
a�-�— Re-roofs
of ApplicanuConuaemr te
H I DOUS MATERIALS DISCLOSURE Type of Roof
W01 Mtn applicant or fretum building aaupanuuu orlundle haurdous msteriat
as dennd by the Cupertino Mu I Code.Chapter 9.13,and the Health and Safety
.Section 25532(a)T All roofs shall be inspected prior to any roofing material being installed.
❑Yes Nu
Will the applicant or future building occupant use equipment or dcvlce+which If a roof is installed without first obtaining an inspection,I agree to remove
emit Mcmuua air conuml den md ray the Bay Ara Air Quatlty Manegemenm all new materials for inspection.
District?
❑Ya ❑Nu
I have mad Me hvaNwer
ov+aials mmimmeu nunder Clupter495 of the Cannor-
niaHealNBSafetyCo .Sat =25505.25533un125534.1unhnudthgifde WAMug
does non Comply have a meant.Na u my mpamibithy m notify Me occupant of the
uI to why leu be met its. faCmirawmf ccui Signature of Applicant Date
owns ler thorizeU adenl // ID All roof coverings to be Class"B"or better