02120005 CITY OF CUPEWI'INO " -
BUILDING DIVISION PERMIT '�COIVTRkTOR INFORMATION:i.A'
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BUI E DPA ER CONSTRUCTION INC PERMITNO2120005
ow9NORLMAN PNINA AND ELI 605 COMMERCIAL ST APPLICATII,2S 013 2002
tor ZONE: (408) 536-0420 SANITARY NO. CONTROL NO.
ARCIIITECT/ENGINEER: BUILDING PERMIT INFO
BLUG ELECT PLUMB MECH
�00 LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing SIDING P
�¢ with Section 7lN Onf DivisinnJnl Ne Businc.4aH��Prnfessinns Gtde,onJ mylicenm
in full Talc��Jk��f IT I ✓ l J
m2Z License Cl. I LK.Y_��G(
to comramur�, ON •3,rf
F=q� ARCHITECT'S
comm
OaU I undcrsmnd my plans xhnll Maxed as Pudic rccnNs C�nt� A
u�3r Licensed Pmfcssinnal �"{lfV ILi^aE®
Ca 1
OWNERBUILDERfrDECLARATION
1 berth lflirm Ilial 1 ore exempt from the Contractors License Law far the $12000
y�p yO following..on.(Sects 7031.5.Business and Prefesxions Code:Any city or county F E 3 'l) 7 2003
%22 which rcqulRx a pemlll h,ennall wl,alter,improve,demolish.(it repair any structure
YI pdnnoits issuance.also myvires the applicam far such Pcrmiuoh eaxigned smlCmcut ���,a
x�x< that he is lice red pursuant to the provisions of the Contractor's Licene law(Chaprer 9 O'�1'(�1'�j gagyyu A&G Valuation
(commencing with Section 9lNNB of Division 3 of the Business and Professions Code)or _"",
L1 S that he is exempt therefrom and the buffs for Ne alleged exemption.Any violation of
Seetion 7031.5 by any applicant for a permit subjects the applicant to a civil penally of 10APNN Occupancy Type
net more Nan five hundred doll...($500). 102 — PIERS
❑ I,as owner of the progeny,or my employees with wages all their sale compensation, 3:8B UFER
will do Ne work,and the structure isnot intended or offered far sale(Sec.7044,Business
and Professions Code:The Committers License Law does not apply to an owner of 104 - REBAR Required Inspections
property who Wildsor improves thereon,and who does such work himselforlbrough his
own employees,provided that such Improvements are not intended omsffered for rete.If, 105 — ANCHOR BOLTS
however,the building or improvement is sold within one year ofenmpletion,the owner- 106 — SEWER & WATER
builder will have the Widen of proving that M did not build or improve for purpose of
sale.). 202 - UNDERFLOOR PLUMBING
❑ I,as owner of the property,am exclusively contracting with licensed contractors la 203 - UNDERFLOOR MECHANICAL
conswct the prolem(Sec.7144,Business and Professions Code:)The Contractor's Li-
renseLawdoesnotapplyloanownerorpropertywhoWihlsorimprowB,ancon.and 204 - UNDERFLOOR FRAME
who contracts for such projects with a contownr(s)licensed purmam to the Cottontails'
License Lew. 205 — UNDERFLOOR INSULATION
❑I am exempt under Sec. BNt PC for rcuon 301 - ROUGH PLUMBING
owase Data 302 — TUB & OR SHOWER
WORKER'S COMPENSATION DECLARATION 303 - ROUGH MECHANICAL
I hereby afEmt under penalty of Perjury one of the following declarations 304 — ROUGH ELECTRICAL
❑Ihaas andwill main tainwum3ame ofCe Labor alPiuure Performance
305 — FRAME
anion,u provided for by Section J]tp of Bic lobar CMe,for she perfonnams of the
work for which this permit is issued. 306 - HOLDOWNS
❑1 have and will maintain Workers Compensation Insurance,as required by Section 3 07 - INSULATION
37W.fthc Lahr Cmr.fnr Ne if emmc of1h Dao kfor which this Perris is issued.
My Workers ore nmol psumn caner and Poliq number ere: 308 — SHEETROCK
C - PmltyNa.: 309 - EXTERIOR LATH
CERTIFI COMPENSATION INSURANCE
310 — INTERIOR LATH
(Otis section need not M completed Rube permit is reran hundred dollars(slro) 311 - SCRATCH COAT
or10S9) 313 - ROOF NAIL
1 aptly that in she Perhtnnat¢c of the..,it for which this Permit is issued.)shall nom 501 - FINAL ELECTRICAL ENERGY
employ any pound in any manurial u to Mcome suhjen to be Workers Compensation
Laws of California.Dale 502 - FINAL PLUMBING ENERGY
Applicant
NOTICE TO APPLICANT:IL after making this Cenilicate of Exemption.you should 503 - FINAL MECHANICAL ENERGY
become subject to the Workers Compensation provisions of the labor Code.you must 504 - FINAL BUILDING ENERGY
ZZ forthwith comply with such provisions sir this Permit shall M calmed revoked. SOS — FINAL ELECTRICAL
.N. CONSTRUCTION LENDING AGENCY —
[r 1herebyaBiomthmthemisaconswctionlendingagencyforthePerformanceof 506 GAS TEST
y > the walk far which this Permit is issued Eim.3097,Civ.C) 507 - FINAL PLUMBING
14A L.endcr's No
<ndrr —
anddryaa 508 FINAL MECHANICAL
U O 1 certify Out l have read this application end stn¢that the above information is 509 - FINAL GRADE
cored.I agree to comply with all city and county drummers and slam laws misting to
0U building convection,and hereby authorim representatives of this city to cmcr upon the 5 FINAL PLANNING
W dhow-memiancdpropcny for inspection purposes. 14 — FIN BLIC WORKS
(We)agree to save,indemnify and keep harmless the City of Carolina against
lyre liabilities.judgments.case and expenses which may in any way accmr against mid City
V Z in consequence of die graining of this Permit. TVSIVJ
^s APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by. Date
SOURCE ATIONS. /
'T- Re-roofs
to A plicanUConbattor Dam
HAZARDOUS MATERIALS DISCLOSU . Type of Roof
W ill the applicam or future building umup.m saorcor handle harardous material
defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Colt Section 25532(.)! All roofs shall be inspected prior to an roofing material bei.. Installed.
❑Yes gats_ P P Y g 8
Will the applicam nr fuwrc building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
,reit hamNous air contaminants as defied by the Bay Amo Air Quality Management all new materials for inspection.
District?
❑Yes
I have mad the harardrus mamrialsmquiremenvi under Chapter 6.95 of the Califor- ,
nit Hcalthgt SafetyCN.Smdon25N15.25533am1255J4.1un&et thmifthe Molding
docs Out currently have a tenant,Nal it is my reap nxibility to notify IM oecupant of thc
rcyuiremenls ichmuslMmrlPriorini. uancenf niticacnf0.cu nyy. atureofApplicant Date
ram orircdagcm Da All roof coverings to be Class n8n or better