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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
��1ICRI�TO�L xURA
BUILDING ADDRESS:
PERMIT NO.
03050024
OWNER'S NAME:
I�RMIT�A 6/ 2 0 0 3
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
P
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
L License Class
License Class Lic. N
TENANT IMPROVEMENT FINALE0 '
'
Date Contractor
ARCHITECT'S DECLARATION
G�
DEC i.J 9 2003
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
BUILDING
1 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 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
$ 3 SVgblotion
(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
3 191 Riil�ez O O
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,
7�T
—d
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
10 2
Inspections
— PIERS p
property who builds orimproves thereon, and who does such work himself or through his
own employees, provided that such improvements am not intended 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
— RE BAR
sale')'
105
— ANCHOR BOLTS
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (See. 7044, Business and Professions Code:) The Contractor's Li-
10 6
—. SEWER & WATER
cense Law does not apply to an owner of property who builds or improves thereon, and ,
202
— UNDERFLOOR PLUMBING
who contracts such projects with a contractor(s) licensed pursuant to the Contractors
License Law
203
- UNDERFLOOR MECHANICAL
❑ I
SCOMPENSATIONDE RATIO
— UNDERFLOOR INSULATION
I hereb rm under penalty of perjury one of the following declarations:
301
— ROUGH PLUMBING
❑ I have and will maintain a Certificate ofConsent to self -insure for Worker's Compen-
302
— TUB be 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
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3
3700 of the Labor Code, for the performance of the work for which this permit is issued.
05
— FRAME
My Workers Compensation Insurance carrier and Policy number are:
306
— HOLDOWNS
Carrier: Policy N
307
— INSULATION
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
308
- SHEETROCK
(This section need notbecompletedifthepermitis(oronehundred dollars ($100)
309
— EXTERIOR LATH
or less.)
310
- INTERIOR LATH
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
311
- SCRATCH COAT'
Laws of California. Date
Applicant
313
501
— ROOF NAIL
- F I NAL 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 shat] be deemed revoked..
502
— F I NAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY
503
- F I NAL MECHANICAL ENERGY
I 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.)
i Lender's Name
505
— FINAL ELECTRICAL
Lender's Address
506
— GAS TEST
1 I certify that I have read this application and state that the above information is
507
— FINAL PLUMBING
correcL I 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 NA ME CHAN CAL
ahove-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
9
t F I N
j liabilities, judgments, costs and expenses which may in any way accrue against said City
5
DISCLOSURE
Will c 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
Godo, Section 553Z(a)?
Ye
❑s
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?�/n
❑ Yes
mad the hazardous materials requiremcnLs under Chapter 6,95 of the Califor-
nia ealth& ShfIely Code, Sections 25505,25533and 25534.1understand that ifthe building
dksnottorte lya tc that it is my responsibility to notiC the occupant o(thc
rents 'eh us el 'or to iss,p a Certificate of ,ppancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
toner authori a nl Date