03050111109
!QO
i0H
�h
'LU
P.
h�
00
-�a
r�ct
ISR
C
V
a
13a
C
0�
W
CITY OF CU PIERTINO
BUILDING DIVISION P ERMUI ['
BUILDING ADDRESS:
CHESTER MAZUR
PERMIT No.
03050111
OWNER'
PERMIT ISSUE DA
05722/2003
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOWSDECLARATION
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
p
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full LicenseClasse and effect. Lie.# __
MASTER BATH
RM REMODEL
Date Contractor
ARCHITECT'S DECLARATION
I understand my plans shall be 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 construe t, 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 Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
$1 Y�V�on
(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
-s AriDDA�TeT,..,,rlvnr. O O
�'1'l'J'V'3+
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
not more than five hundred dollars ($500).
..3rc9�7
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
101 —
FOUNDS} Inspections
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 of
property who builds or improves thereon, and who does such work himself or through his
102 —
PIERS
own ent ployca. provided that such improvements am not intendett or offered for sale. If,
103 —
UFER
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
sale J,
105 —
ANCHOR BOLTS
❑ 1, as owner of the property, am exclusively contracting with licensed contractus to
construct 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 0 2 —
UNDERFLOOR PLUMBING
License Law.
203 —
UNDERFLOOR MECHANICAL
C]
TION
205 —
UNDERFLOOR INSULATION
l hereby affirm under penalty of perjury one of &o4ollowing declarations:
301 —
ROUGH PLUMBING
❑Ihave and will maintain aCertificate ofConsent toself-insure for Worker'sCompen-
302 —
TUB & OR SHOWER
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
303 —
ROUGH ME CHAN I CAL
work for which this permit is issued.
304 —
ROUGH ELECTRICAL
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
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 arc:
306 —
HOLDOWN S
Carrier. Policy No.:
CERTIFICATE OF EXEMMON FROM WORKERS'
307 —
INSULATION
COMPENSATION INSURANCE
308 —
SHEETROCK
(This section need not be completed ifthepermit isfor one hundred dollars ($10()
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 la become subject to the Workers' Compensation
311 —
SCRATCH COAT
Laws of Califomia. Date
Applicant
313 —
5 01 —
ROOF NAIL
FINAL ELECTRICAL ENERGY
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
502 —
F I NAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY
503 —
FINAL ME CHAN I CAL ENERGY
1 hereby affirm that there is a construction lending agency for the performance of
504 —
FINAL BUILDING ENERGY
the work for which This permit is issued (Sec. 3097, Civ. C.)
� Lenders Name
505 —
F I NAL ELECTRICAL
Lender's Address
506 —
GAS TEST
1 certify that I have read this application and state that the above information is
corrttL 1 agree to comply with all city and county ordinances and state laws relating to
507 —
F I NAL PLUMBING
building construction. and hereby authorize representatives of this city to enter upon the
F I N L ME C I CAL
+ ahove-mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
FI
liabilities, judgments, costs and expenses which may in any way accrue against said City
NG
in consequence of the granting of this permiL
l/'
D WILL COMPLY WITH ALL NON -POINT
+ APPLIC UNDE
9/) 2'10
Re -roofs
Signature ApplicanUCon Date
of for
HAZAKDOLIS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or tuturc building occupant store or handle bazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
`�
All roofs shall be inspected prior to any roofing material being inst lled.
❑Yes Y�7 No
future
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or 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 r-kAo
I have read the hazardous materials requiremcn under Chapter 6.95 of the Califor-
niaHealth Safety Code, Sections 25505,25533andMun nderstandthat ifthe building
docs n urtendy have a to ant that it is my responsibility t no y the occupant of the
'
rcyui ro471 up by.
Signature of Applicant
Date
All rnnf rnvi-rinor- to ht-. ('lace "R" nr hPttPr