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02090085Z C0C �z 17 ri 't� e 06 tr, gygg40 y Inc CITY OF CUPERTINO errnor A lr� � IN) BUILDING DIVISION �E,i'Rj�jjr BUILDING ADDRESS: PERMIT NO. 21853 MONTE CT p2QQnnAr:; OWNER'S NAME: PERMIT ISSUE DATE 2003 PHONE: SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: 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 wlth Section 7000) of Division 3 of the Business and ProlessionsCode, and my license is in full force and effect. ADD 774 S Q . FT . / REMODEL License Class Lie.tl Date Contractor ARCHITECTS DECLARATION I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractors 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 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 $10 M199tlon (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 AV& MifffiBer 0 0 . Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). ❑ I, as owner of the property, or my employees with wages as their sole compensation, 10 1 -FOU d Inspections p will do the work, and the structure is not intended oroffered forsalc (Sec. 7044, Business and Professions Code: The Contractors License Law docs not apply to an owner of 10 2 — PIERS_ property who builds or improves thereon, and who does such work himself or through his - own employees. p yces,providcdthatsuchimprovcmcntsarcnotinrendedoro[feredforaale.if, - - - 103 — - --- --- -- - --- —� UFER however, the building or improvement is sold within one year of completion, the owncr- builder will have the burden of proving that he did not build or improve for purpose of 104 — REBAR '`)• 105 — ANCHOR BOLTS 1, as owner of the property, am exclusively contracting with licensed contractors to 10 6 — SEWER & WATER construct the project (Sec. 7044, Business and Professions Code:) The Contractor's U- censc Law docs not apply to an owner of property who builds or improves themon, and . 202, — UNDERFLOOR PLUMBING who contracts for such projects with a contractor(s) licensed pursuant to the Contractors License Law. 203 — UNDERFLOOR MECHANICAL ❑ 1 am exempt under Sec. �% B & P C f r this anon 204 — UNDERFLOOR FRAME o er! �� -'—I WORKER'S COMPENSATION DECLARA N 205 — UNDERFLOOR INSULATION 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 scif-insum for Worker's Compen- sation, 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.*304 — ROUGH ELECTRICAL C]I 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 issued. , My Workers Compensation Insurance carrier and Policy number are: 306 - HOLDOWNS Carrier. Policy No.: 307 — INSULATION MPEN ATION INS RANCEON FROM ORKERS' cERTIFtcCOMPENSATION 308 — SHEETROCK (This section need notbecompletedifthepermltlsforonehundreddollars(5100) 309 — EXTERIOR LATH or less.) ... .. _ _. 310 — -INTERIOR- LATH-._. I certify that in the perfon�cp pf the work for which this permit is issued, l shell not work em to an rsanln m rso to c t Workers'Com enation Laws of Calif m, arm �" . ZCIt p Applicant,_ 311 — 313 — SCRATCH COAT ROOF NAIL NO ICE O PLICANT: If, after making this Certificate of Exemption, you should S01 — FINAL ELECTRICAL ENERGY becoubject 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 - F I NAL PLUMBING ENERGY 503 — FINAL MECHANICAL ENERGY CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of 504 — F I NAL BUILDING ENERGY 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 I have read this application and state that the above information is 507 — FINAL PLUMBING correct. l agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the F I N ME CHAN . CAL ahove-mentioned property for inspection purposes. k0 9 F I N (We) agree to save, indemnify and keep harmless the City of Cupertino against j liabilities,judgments, costs and expenses which may In any way accrue against said City 5 NG in consequence of the granting of this pc, it. APPLICANT UN ERSTANDS AND" ILL COMPLY WITH ALL N NPO Issued by: 5 C WORKS Date SOU CE G ATIO St r 5 Re-roofs Type Of Roof gnatur ofA plicant/Contracter D HAZARDOUS MATERIALS DISCLOSURE 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(a)7 ❑Yes .�'No 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 Arca Air Quality Management all new materials for inspection. District? El Yes 92 _ 2No I have read the hazardous materials requirements under Chapter 6.95 of the Cali for- niaHealth&SafelyCode, Sections 25505,25533and 25534.1understandthat ifthc building docs not currc ly have a tenant, that it is m responsibility t no ty the occupant ofpc rcr ulrcm hich ustbemctpr�oI w su eeora crift tr, r up Signature of Applicant Date All roof coverings to be Class "B" or better Ovljfdr or authorized agent D