02110062CITY OF CUPER'1'INOw
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BUILDING DIVISION PERMIT
CONTRACT,OWINFORMATION.
1UI[tb5(j,2oDRBGLLINGER RD
PERMITNO2110062
owFiIIlTiWD YAP
APPLICATMS✓I®ITj2002
IONS:
SANITARY NO.! CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INPO
BLDG ELECT PLUMB MECH
0 0 0 0
Lm fNSEU CONTRACT'OR'S DECLARATION
Of hap
1 nemnr affirm mal 1 am fieenaca ander provisions nr cntpmr 9 (commencing
Job Description
PROPERTY C/ O p
with Rcc,1 Division hof me Busin�Nno Professinm G,Jc, unJ mylicene is
{�
F=INALE
�OTX/lB�)of
in full li,rca effect ✓
,WALE®
Liccne Clu. Lic, p I
[3
/ / —b —O Cam
ARCHI�n erste m a,,hnlIEer$D RATION
d I J y plans mollbeusW as Ouhlic rcrnNs
MAY 0 7 2003
Liccnscd 11 ficssinnal
OWNER-BUILDER DECLARATION
I ,ILQ
1 herchyreaso .Ilion that I am oBusin from the Cssions era License for me
g u
W a
followingreason.a. o
7031.5. Business and Cute: Any city nr mushy
an : city
which improve, demolish,
Permit u, alar. pmprose, demolish, nr
acquires Pamir air any location,
its n uinmma,
printm its issuance,ako rsuantto res the applicant fe, Co melor'pcomi mice s Law(ed saamenl
e s ement
that pumuummthe oRha Conainessand
3&}9 R141FJf6b?A@@ Valuation
mecccmed
of Dispom
(cwith Division 3 of the Business exe and ProclawlCnoPrcrY
Codd or
Oat he is axe cm(ro andXXB the on. Any
Net he is exempt themfrom and doe bazis for me allege) exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant a civil penally of
five hundred dollars
PNN Occupancy Type
not mom than TssO)).
202 - UNDERFLOOR PttUMBING
0 I, az owner ofine property, or my employees with wages es their sole compensation,
will do the work, and the stracmrc is not intended or offered for sale (Sec. 70voa, Business
Bel: RE)UGH
and Professions Code: The Cmuranors License Law docs not apply to an owner of
302 - TUB & 9 gRetions
property who Wilds or improve thereon. and who does such work himselfor through his
pmvpded that such improvm ememaanoummnded ormfered forsala If,
502 — FINAL PLUMBING ENERGY
hwnemployces.
ever. the building or improvement is sold within one year ofcnmpletiot, the owner-
builder will have the W ,den of proving Out he did not Wild or improve fur purpose of
sale).
507 - FINAL PLUMBING
❑ 1, as owner of the propertyam exclusively contracting with licensed contractors m
construct the project (Sec. 70Sa, Business and Professions Code:) The Conuanor's Li-
cense law does not apply to an owner of property who Wilds or improves tremors, and
who vontmfL for such projects with a confusions) licensed pursuant In the Conlfacior's
— -
License Law.
C]I am exempt under Sce. ,B&P C for this Mason
Owner Date
WORKER'S COMPENSATION DECLARATION
J
1 hereby affirm under penalty ofperjury one of the following declaratWorker's
V
1 have and will u, of consent m self for Co
for Section37W cifoor ante ofcn-
for by Section )700 of d¢ faWr CMe, for the pertormana of the
Work, r hick me
work for which this permit is issued.
mi
❑ I have and will maintain Workers Compensation Insurance, ash Section
p
JJlp of dm laWr, C,Je, for the pertormantt of cwork for which this permit is issued.
his cm , i
My Wufkers am cation mncc amicrond ynumber am:
CER IFICATE OF EXE ION FlIo WORKERS'
COMPENSATION INSURANCE
(Thin aretion need not be eomplcao it the petmil is forma hundmJ JoOam o l0f)
less.)
I cenify that in the perlinmance, of the work for which this permit is issued, I shall not
employ any person in any manner an all m become Subject n Inc Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: 11, aIle, making This Cenilicale of Exemption, you should
Became subject to the Worker's Compensation provisions of the lalvr Code, you must
forthwith comply with such provisions or This permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm mal there is a construction lending agency lot the performance of
the work for which this pclmil is issued (Sec. 3097, Civ. C.)
Lender's Name
---
I<nder's Address
1 certify mal I have read this application and Safe that the above information is
correct. l agree to comply with all City and county ordinances and sale laws minting to
building construction, and hereby authorim reprcmnefeWs of this city to ente4maWnal Be
alcove-memioneo pmpeny for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cuperti
liabilities, judgments, costs and e.rpcnses which may in any way accom agains
APPLICANTc NDIERaFANDng fOps permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH p NOIssued
by:
�I 1
S RCF ULATIONSS
Date
X
f ��
Stg ofAppGntiano, DateRe-roofs
HAZAR DOU S MAI'LRIALS DISCLOSU REType
of Roof
Will me applicant or future building Occupant smm or handle ha amo a
as defined by the Cupertino Mum at Code, Chapter 9.12, and the HOMO and Safety
Gale, 2ss32(a)7
0yb.,
❑ Yes Nn
All roofs shall be inspected prior to any roofing material being installed.
Will mea applicant or future building execution oro,
PP b P
If a roof is installed without first obtaining an inspection, I agree to remove
g p
rQuordManawhich
•milia, uxair cnnWminanfxasJcOncJbythe Bay ArcaAirQualifyMawgcmcnt
a Air
DixlliCl/'
all new materials for inspection.
Ycs
❑
I have read the ha,atdous mmerials requirements under Chapa r6.95 of the Culifor-
niallcalth&SdClr C(J.Sadom25N)5,25533md255N.1umkrsandthalifmc Wilding
docs ran cuare nIll have a beam, mal pt is my rcsrymsibiln, In nndly tW occupant of the
require is wmc tbemet poor u, issu:mcco( a ccm0ce10.cuptncy.
Signature of Applicant Dale
�i
All roof coverings to be Class "B" or better
Owner orouthorPmdagent Date