02110133BUILDING DIVISION PERMIT
BUILDING ADDRESS: NELSON PLUMBING PERMIT NO.
1107 STEEPLECHASE LA . 02110133
OWNER'S NAME: 15,33 ALTA GLEN #1 APPLICATION SUB DATE
408)280-5311 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
w0 p LICENSED CONTRACTOR'S DECLARATION
ry v f= I hereby affirm that I am licensed u der ovisions of Chapter 9 (commencing
with Section fore 7000 of Division 3 of the Busin rid Professions Cade, and my license is
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a y in full
r�, z Liccnsc CI7 " Li .
o z �- G te CcntraN
P 14Y F- � ' ARCHITECT'S D ARA IO
g C � < 1 understand my plans shall be used as public records
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m 3
U. t, Licensed Professional
y
0,:
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
W 00 following reason. (Section 7031.5, Business and Professions Code: Any city or county
><$_ K which requires a permit to construct, alter, improve, demolish, or repair any structure
ul
l..z prior to its issuance, also requires the applicant for such permit to file a signed statement
a that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
CF (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
a that he is exempt therefrom and the basis for the alleged 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).
❑ 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 owner of
property who builds or improves thereon, and who does such work himselfor through his
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 completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense Law does 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
License Law.
+•� Date ' r I �J • y3
1 hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
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:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars ($100)
or less.)
1 certify that in the perfo ce.of the w-rk [or which this permit is issued, I shall not
employ an
- '
pl' a
E o APPLICANT: f, or making ' enificate of Exemption, you should
come subject to the Worker's Compensati06 provisions of the Lahor COdc, you must
0 Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
�•
E•+ ►-r 1 hereby affirm that there is a construction lending agency 1'nr the performance of
the work for which this permit is issued (See. 3097, Civ. C.)
W ALender's Name
4Z
Lender's Address
U 0 I certify that I have read this application and state that the above information is
;.Tn r"' correcL I agree to comply with all city and county ordinances and state laws relating to
0 U building construction, and hereby authorize representatives of this city to enter upon the
r U above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
F"r V) liabilities, judgments, costs and expenses which may in any way accrue against said City
C) z inconsequence of the r; ti o is pe
r r APP UNDERST S N 1 C PLY WITH ALL NON -POINT
SO
1nature of ApplicantlConlractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hawrdous material
as defined by the Cupertino Mun' 'pal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑Yes No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants defined by the Bay Area Air Quality Management
District?
❑Yes No
I have read the hazardous material quirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 255 3 255 .1understand that ifthe building
docs not
Date
BUILDING PERMIT INFO
BLDG ELECT PLUMB
Job Description
ADD 1395 SQ.'FT./REMODEL
Sq. Ft. Floor Area $14 9 3ldlfation
-5 b A014 t46jjJl)eV 0 Occupancy Type
102 - PIERS Required Inspections
103 -
UFER
104
- REBAR
105
- ANCHOR BOLTS
106
- SEWER & WATER
202
- UNDERFLOOR PLUMBING
203
- UNDERFLOOR MECHANICAL
204
- UNDERFLOOR FRAME
205
- UNDERFLOOR INSULATION
301
- ROUGH PLUMBING
302
- TUB & OR SHOWER
303
- ROUGH MECHANICAL
304
- ROUGH ELECTRICAL
305
- FRAME
306
- HOLDOWNS
307
—INSULATION
308
- SHEETROCK
309
- EXTERIOR LATH
310
- INTERI.OR LATH
311
- SCRATCH COAT
313
- ROOF NAIL
501
- FINAL ELECTRICAL ENERGY
502
- FINAL PLUMBING ENERGY
503
- FINAL MECHANICAL ENERGY
504
- FINAL BUILDING ENERGY
505
- FINAL ELECTRICAL
506
- GAS TEST
507 - FINAL PLUMBING /
5FINAL MECHANICAL G
509
- FIN E
5
N G
Issued by51
- WORKS Dat /
Type of Roof
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
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class "B" or better