03060069CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMIT NO03060069 3060069
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ER'S NAME:
PLRMIT Iss�E�n7g, 9 / 2 0.0 3
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SANITARY N0. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
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LICENSED CONTRACIOWS DECLARATION
per 9 (ro encing
1 tumby affirm Thar I sm limmucm under pmvWona of Chamm
o
Job Description
P
with Sactlon 7000) of Divhion 3 of me Business and professorial Code. same my licence, is
in full forte and effect.
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Dau Commucimr
ARCHITECTS DECLARATION
I understand my plans shed M used or public rooms
DEC 0 8 2003
Licensed Poefcssirml
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am esempl from du Contractor's License Law far the
following motor. (Seamon 7031.5. Business and Prefetium Code: Any city or county
BUILDING
demolish. air any solutions,
reqes w uba Permit construct. alur, improve,m rep
prior in is assumed. also mquims tie aPPliranl forsuch permit to rile a signed statement
that he is licensed pursuant o dc provisions of the Contractor's Uccom law(Clupur9
Sq. Ft. Floor Area
$�"Stion
(commencing wits Section 7000) of Division 3 of the Baines and Protest... Code) tar
that be is exempt therefrom and the hub for the alleged exemption. Any violation of
3 AF3 PAIb8er 0 0
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
not mom than live hundred doll.. ($500).
0 1, u owmr of de pmpWy, or my employees with wag. u Nair ms c=Mnadw,
i U i—d Inspections
P
will do the work and the swmum lsm(imended oronend formic (Sm. 7014, Business
and Profes.tmm Code: The Conuacur's Littnte Law does but apply m an owner of
102 — PIERS
property who Mildsm tmpmvss thercon,rudwho doessucn wort nimseHmthmagh his
own employees, provided the such irepmvemenu se not intended monued for We. If.
103 — UFER
however, the Wilding or improvement is sold within am year of comPledon. the owner.
Wilder will haus the trustee of proving WI he did not Wild or improve for purpose of
104 - REBAR
105 - ANCHOR BOLTS
ipl am owner of the property. am exclusively contracting with licensed contracmn m
106 SEWER & WATER
omwct the project (Sec. 7044, Business and Proresslom Cade:) The ConuacmM1 L6
—
,
come law does noupply to an owner o0 property who Wilds or treprow we.on. and.
202 — UNDERFLOOR PLUMBING
ued punnte Constitutes
for ooh pm)ccu with rconuanor(q licensed m N
License LoWu
203 - UNDERFLOOR MECHANICAL
0un common undo .B&PC fm mi. or
204 - UNDERFLOOR FRAME
205 - UNDERFLOOR INSULATION
ER's COMPENSATION DEC ON
a Mmbyafromunderpenstyofpduryomofthefolimingdecluatlom:
301 - ROUGH PLUMBING
"baveandwillmelnaltn.Cartir"mof
302 — TUB & OR SHOWER
once waeB.imurefor Worker's Compon•
,
motion, as provided for by Section 3700 of the labor Code, for the pesarmamx a0 the
303 - ROUGH MECHANICAL
work for which this permit is issued.
304 - ROUGH ELECTRICAL
0 1 have and will maintain Worker's Compensation Insurance, as required by Semon
370D of the Labor Co le, for dm performance of them wort forwhich this permit to issued.
305 — FRAME J -/
My WorkcYa Compensation Insurance carrier and Policy number am:
306 — HOLDOWNS C / -.
Carrier: Policy No.:
307 - INSULATION -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
308 - SHEETROCK
iftenoln isformed hundred dollars(SIW)
into seetiro recti not Wcomploudh p
309 - EXTERIOR LATH `
orl"a)
I "Wiry n in th h rmanee of the irk rat 'ch This, t u issued, I Mill not
r'
310 - INTERIOR LATH
employ any.
_
313 - ROOF NAIL
501 '- FINAL ELECTRICAL ENERGY
�QPPI'¢¢oral
IWjOCE TO APPLICANT. If. .fur making this Ccniftcam or Exemption, you should
b now Subject se the Workcri Compensation provisions of the Ishan Codc, you most
forthwith comply with mesh pmvtsem or this Pcrmiuhall W emend revoked.
502 — FINAL PLUMBING ENERGY
503 - FINAL MECHANICAL ENERGY
CONSTRUCTION LENDING AGENCY
IWnby sRrm mat dem i.. construction lcedong.gocy ran the perimme star
504 - FINAL BUILDING ENERGY
the work for which this Permit bissued (see . 3097, Cit. C.)
505 FINAL ELECTRICAL
Lender's Nurse
-
506 - GAS TEST
LenderaAdd.
I certify that I have read this application and sum that the about information is
507 - FINAL PLUMBING
correct. I agree to comply with all tiny and county ordinances and sou laws refining m
Wilding crnalruttion, and hereby sothedn representatives of this city m enur open the
— FINAL MECHANICAL
abarcmcntiomd property for inspection purposes
O FI
(We) agree in save, indemnify sad keep harmless the City of Cupertino againstliabilities,
judgments, cats and expenses whim may in my way accrue agaiml amid Ch y
NG
in consequence of the grendng of this permit.UW
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NO -P NT
Issued by: 5 WORKS Dat
SOURCE
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Re-roofs
Re -roofs
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sun o ou
MATERIALS DISCLOSURE
Type of Roof
Will that applicant or future Wilding occupant sort or handle hsardou material
s darned by that Cupertino Municipal Code. Chapter 9.13. and the Hesllh and Safety
Section 25532(')? 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 forum Wilding occupant use equipment or devices whim
It haromom air comment ... ts me defined by the Bay Area Air Quality Management
all new materials for Inspection.
oVicl7
❑Yes A.
I have mad me In ardnusmserudlinu u mmcnts under Chapmr 6.95 of me Califor.
,
nim HesW&Safety Code,Sam.u25505.25533a 75534.Iundenunddmifthe Wilding
data not currently how a meant, that it u my respomlMlity m notify do t of the
ngmremcnta
n e