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03020054goo <� ,vC�2 nF yCj d.i 3yUF- COQ W OC km� y"rr ZZs a 0 :2 V C z� H t% r ka � UC V. F O� i� ►�.t G U� CITY OF CUPERTINO BUILDING DIVISION PERMIT 12 �N�'C R Affl�� o V'�l A ' Maw BUILDING ADDRESS: PERMIT NO. OWNER'S NAME: PERMIT gi2 dAY1r_ SANITARY NV 0 OL NO. ARCHITEC (ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing Job Description with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effecL LlccnseClass Lic.N ADD 639 SQ . FT . L . / 676 SQ . FT . GARAGE Date Contractor ARCHITECT'S DECLARATION 1 understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the following reason. (Section 703 1.5, 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 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 $ 9 SVpI8q6ion (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of 3 ALM 1$9170Sr 0 0 Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than Eve hundred dollars (M). ❑ 1, as owner of the property, or my employees with wages as their sole compensation, 101 — FOUND7�{'f+ �7�7 ' Inspections will do the work, and the structure isnot intended oroffered forsalc(Sec.7044,Business and Professions Code: The Contractor's License Law docs not apply to an owner of property who builds or improves thereon, and whodoessuch work himselfor through his 102 CECI]t'f'3d — PIERS own employees, provided that such improvements are notintended oroffered for sale If. 10 3 — OF ER however, the building or improvement is sold within one year of completion, the owner- builder will have the burden of proving that he did not build or improve for purpose of 104 - REBAR 105 — ANCHOR BOLTS zI)., as owner of the property, am exclusively contracting with licensed contractors to tract the project (Sec. 7044, Business and Professions Code:) The Contractor's U- 106 - SEWER & WATER cense Law docs not apply to an owner of property who builds or improves thereon, and, who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's 2 2 _ UNDERFLOOR PLUMBING License Law, 0;1 c. . B & P C or this anon204 203 - UNDERFLOOR MECHANICAL ` — UNDERFLOOR FRAME �arnexe�Under Date: E MPEN ATIONP• LARATION 205 — UNDERFLOOR INSULATION I hereby afrnmunder penalty of perjury one of the following declarations: 301 — ROUGH PLUMBING ❑ 1have and will maintain aCertificate ofConsent toself-insure for Workees Compen- 302 — TUB & OR SHOWER station, as provided for by Section 3700 of the Labor Code, for the performance of the 303 — ROUGH MECHANICAL work for which this permit is issued. ❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section 304 — ROUGH ELECTRICAL 3700 of the Labor Code, for the performance of the work for which this permit is issued. 3 05 — FRAME My Worker's Compensation Insurance carrier and Policy number arm 306 — HOLDOWNS Cartier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' 307 — INSULATION COMPENSATION INSURANCE 308 — SHEETROCK (This section reed not be completed ifthepermit isfor one hundred dollars (5100) 309 — EXTERIOR LATH or less.) I certify that in the performance of the work for which this permit is issued, I shall not 310 — INTERIOR LATH employ any person in any manner so as to become subject to the Workers' Compensation 311 — SCRATCH COAT Laws of California. Date Applicant 313 501 — ROOF NAIL — FINAL ELECTRICAL 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 forthwith comply with such provisions or this permit shall be deemed revoked. 502 — FINAL PLUMBING ENERGY M ' CONSTRUCf1ONLENDING AGENCY + 503 — FINAL MECHANICAL ENERGY 1 hereby affirm that them is a construction lending agency for the performance of 504 — FINAL BUILDING ENERGY y the work for which this permit Is issued (Sec. 3097, Civ. C.) Lender's Name 505 — FINAL ELECTRICAL Lender's Address 506 — GAS TEST 1 certify that 1 have read this application and state that the above information is + correct. 1 agree to comply with all city and county ordinances and stale laws relating to 507 — FINAL PLUMBING building construction. and hereby authorize representatives of this city to enter upon theFIN MEC CAL above-mentioned property for inspection purposes (We) agree to save, indemnify and keep harmless the City of Cupertino against 09 FI j liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. 5 ( VN�G APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -P01 Issued by: 5 C WORKS Date S R ULA S. Re -roofs 2S Si a f A scant/ ontractor HAZARDOUS MATERIALS DISCLOSURE I Type of Roof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, section 25532(.)? �No❑Yes All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑ Yes I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building docs not currently have a tenant, that it is my responsibility to notify the occupan of the rc of a Cenift to of occu Z 9 Signature of Applicant Date All roof coverings to be Class "B" or better 1:1 Date' �Or CITY OF CUPERTINO BUILDING DIVISION PERMIT����� ITY"VD ROLINE DR � PERMIT NOD3050002 PERMrr rssUgn 1/ 2 0 0 3 PHONE: SANITARY NO. CONTROL NO. ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION 1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing Job Description with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full a and effect. Licenensee Clara Lk. N REVISION --IN HOUSE USE ONLY Date contractor NO NEW PERMIT, ORIG. #03020054 ARCHITECTS DECLARATION I understand my plans shall be used as public records ELEVATION/GARAGE/DOORS OPENING 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 Cote: 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 for such permit to rile a signed statement that he is licensed pursuant to the provisions of the Conuxlor s License Law (chapter 9 Sq. Ft. Floor Area Valuation (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basic for the alleged exemption My violation of APN Number�1@y Type Section 7031,5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (E500). ❑ 1, as owner of the property, or my employers with wages as their sole compensation, Required Inspections will do the work and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: Contactors License Law dos not apply to an owner of 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 We. If, 101 — FOUNDATION however, the building or improvement is sold within one year of completion, the owner - builder will have the burden of proving that he did not build or improve for purpose of 102 — PIERS sale.)' 103 — UFER ❑ I, as owner of the properly, am exclusively contracting with licensed contractors to 104 REBAR construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li. - cense Law does not apply to an owner of properly who builds or improves thereon, and, 10 5 — ANCHOR BOLTS who contracts for such projects with a conuactor(s) licensed pursuant to the Contractors License Law. 106 — SEWER & WATER ❑ 1 am exempt under Sec. , B & P C for this mason 202 — UNDERFLOOR PLUMBING oe"1G7°ate 203 — UNDERFLOOR MECHANICAL WORKER'S COMPENSATION DECLARATION 204 — UNDERFLOOR FRAME I hereby affirm under penalty of perjury one of the following declarations: 0 have and will maintain a Certificate of Consent to self-insutefor workeescompen- 205 — UNDERFLOOR INSULATION sation, as provided for by Section 3700 of the tabor Code, for the performance of the 301 — ROUGH PLUMBING world for which this permit is issued. 302 — TUB & OR SHOWER ❑ I have and will maintain Workers Compensation Insurance, as required by Section 3700 of the Labor Cede, for the performance of the work for which this permit is issued. 303 — ROUGH MECHANICAL My workers Compensation Insurance carrier and Policy number are: 304 — ROUGH ELECTRICAL Carrier. Policy No.: 305 — FRAME CERTIFICATE OF FxFmF TON FROM WORKERS' COMPENSATION INSURANCE 306 — HOLDOWNS (This section need not be completed if the permit is foronc hundred dollars (SI00) 307 — INSULATION orless.) 308 — SHEETROCK 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'Compensation 309 — EXTERIOR LATH Laws ofCalifornia. Date 310 — INTERIOR LATH Applicant 311 — SCRATCH COAT NOTICE TO APPLICANT: If, after making this Cenificatc of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Cock, you must forthwith comply with such provisions or this permit shall be deemed revoked. 313 — ROOF NAIL 501 — FINAL ELECTRICAL ENE CONSTRUCnONLENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of 502 — F I NAL PLUMBING ENE R the work for which this permit is issued (Sec. 3097, Civ. C.) Lenders Name 503 504 - FINAL ME CHAN I CAL E R — F I NAL BUILDING EN G Lenders Address 1 certify that I have read this application and state that the above information is 505 — FINAL ELECTRICAL correcL I agree to comply with all city and county ordinances and stale laws relating to building construction, and hereby authorizt representatives of this city to enter upon the50e*GAS E S T above-mentioned property for inspection purposes (We) agree to save, indemnify and keep harmless the City of Cupertino against 0 7 F I N liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit 5 �IC AL D� / APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by:5 Date J SOURCE REGULATIONS, Re -roofs 514 — INAL PUBLIC WORKS Signature of Applicant/Contractor Datc HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety 25532(4)? Code,Yes All roofs shall be inspected prior to any roofing material being installed. ❑ Ya ❑ No [I If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑ Yes ❑ No I have read the hazardous materials requirements undcrChaplcr 6.95 of the Califor- nia 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 priorto issuance of a Certificate of Occupancy. Signature of Applicant Date All roof coverings to be Class "B" or better Owner or authorized agent Dae