02060167CITY OF CUPERTINO
BUMDING DIVISION PERMivwo,
CONTRACTOR INFORMAT�1N-
BUILDING ADDRESS:
PERMIT NO.
19055 PRUNERIDGE AV
02060167
OWNER'S NAME:
APPLICATION SUB DATE
AMES AVENUE ASSOCIATES
06/25/2002
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70 ) of Division 3 of the Busingk9 and Professions Code, and my license
��
INSTALL CEILING/LIGHTING/
is in full for d effect.
License Class Lic. # J'
REGISTERS
Co
V
V ARCHITECT'S [ARATION
1114I#M B
be V
1 understand my plans shall used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
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,
prior to its issuance, also -requires the applicant forsuch permit to file a signed statement
.S q. Ft.,FIOOc
Area• , .t -
aluatlon
that he it licensed putsuant tdrho provisions of the Contractor's License Law (Chapter 9
Section 7000) Division 3 Business
(commencing with of of the and Professions Code)
_ "
,
'
or that he is exempttherefrom and the basis for the alltged 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).
Umber
Occupancy Type
❑ I, as owner of the property, or my employees with wages as their sole compensation,
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
102 -
PIERS Required Inspections
owner of property Who builds or improves thereon, and who does such work himself
his
10 3 —
UFER
or through own employees, provided that such improvements are not intended or
offered for sale. If, however, the building or improvement is sold within one year of
10 4 —
_
REBAR
completion, the owner -builder will have the burden of proving that he did not build or
improve for purpose of sale.).
105 -
ANCHOR BOLTS
d 1, as owner of the property, am exclusively contracting with licensed contractors to
106 —
SEWER & WATER
construct the project (Sec. 7044. Business and Professions Code:) The Contractor's
License Law does not apply to an owner of property who builds or improves thereon,
2 02 —
UNDERFLOOR PLUMBING
and who contracts for such projects with a contractor(s) licensed pursuant to the
203 —
UNDERFLOOR MECHANICAL
Contractors License Law.
❑ I 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 affirm under penalty of perjury one of the following declarations:
302 —
TUB & OR SHOWER
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's
303 —
ROUGH MECHANICAL
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
304 —
ROUGH ELECTRICAL
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
305 —
FRAME
3700 of the Labor Code, for the performance of the work for which this permit is
306 —
HOEDOWNS
issued. My Co e: cation insuran�eer anFR Policy number are: re:
Polic V /U
307 —,
INSULAT I"ON "
y RTIF CATION OF EXEM N O WORKERS'
308 -
SHEETROCK '
COMPENSATION INSURANCE
309 -
EXTERIOR LATH -
(This section need not be completed if the permit is for one hundred dollars
(S100)arless.)
310 -
INTERIOR LATH
311
SCRATCH COAT
I certify that in the performance of the work for which this permit is issued, I
_
shall not employ any person in any manner so as to become subject to the Workers'
313
ROOF NAIL
s Compensation Laws of California. Date
Applicant
501 —
502 —
FINAL ELECTRICAL ENERGY
FINAL PLUMBING ENERGY
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
a forthwith comply with such provisions or this permit shall be deemed revoked.
503 —
FINAL MECHANICAL ENERGY
CONSTRUCTION LENDING AGENCY
504 —
F I NAL BUILDING ENERGY
I hereby affirm that there is a construction lending agency for the performance
of the work for which this permit is issued (Sec. 3097, Civ. C.)
505 —
FINAL ELECTRICAL
Lender's Name
Lender's Address
506 —
GAS TEST
507 —
F I NAL PLUMBING
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
508 —
F I NAL ME CHAN I CAL
to building construction, and hereby authorize representatives of this city to enter upon
the above-mentioned property for inspection purposes.
509 —
F I NAL GRADE
(We) agree to save, indemnify and keep harmless [he City of Cupertino against
510 —
F I NAL I NG
liabilities, judgments. costs and expenses which may in any way accrue against said
City in consequence of the granting of this permit
L'NDERSTA. S A \ COMPLY WITH ALL V VT
%14 �—s
F A WORKS
SOpL1CANT -P
Issuedy
Date
tgnature of Applicant/Contractor ate
Re -roofs 'f
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stop: or handle hazardous material
Type .of Roof
as defined by the Cupertino Municipal Code, Chapter 9. 12, and the Health and Safety
Code, Section 25532(a)?
OYes No
All roofs shall be inspected prior to any roofing material being installed.
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
az d
emit hazardous air contaminantsed by the Bay Area Air Quality Management
District?
all new materials for inspection. Applicant understands and will comply with
❑Yes 0 N
all non -point source
regulations.
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533 and 25534, 1 understand that
if the building does not currently have a tenant, that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance o((a Cerr//ficat of
cc ancy. \ /J�
�(J
ignature of Applicant
Date
,
All roof coverings to be Class "B" or better
Owneer authorized agent Date
OFFICF