03090217 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTORJNF.QRMATION r:,
BUILDING ADDRESS: PERMIT"003090217
10415)4 D7MPqTRR AV
YERS NAME: PERMIT ISSUE DATE
PRICE HAROLD 2003
PHONE: SANITARY N0, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLOMB MECIi
loo LICENSED CONTRACTOR'S DECLARATION O O O O
Job Description
tu P 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
`Zw with Scaion l01N17 of Division3ofthe Businev and mfexami Cale.and my license is
in .anaurzet. i sZ ADD 98 SQ. FT T gE REMODEL
7v�? Licca C s�F�— Contractor
intr ri—rr ee���i1
Dam s Cunlonar
qq CH �CTSD la ION
F W—t I ts sem p s Mus title reds '
' JUN 0 12004
cense Ifessional
r OWNER-exempt frDECLARATION
a 0 1 hereby maso affirm the 1 1. exempt from the Contractor's Co License Law Ire iM
o� following mason.(Semon 1arrovi Business and processions Cal.:Any inn m county BUILDING e m which reyuirs a pcemil sen ennsvuer alcor,improve.Jcmplixh,m repair any structure � 0
°iy prior In its issuance.also requires the applicant for such permit s°rile asignedsuumem
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
eFO (commencing wi th Section 7")of Division 3(if the Business and Professions Code)or
i N R Nat he is exempt therefrom and the basis for me alleged exemption.Any viNmian of 3264 8025 . 00
Section 7071.5 by arty applicant for a permit subjects the applicant to a civil penally of AIN Number - Occu ane Type
not more Iran five hundred dollars(5500). P Y YP
❑ I,as owner of the property.or my employees with wages As their sole compensation,
will do she work.and the swcmre is not imendcd or offered for sale(Sec.7061,Business
and Professions Code:The contractors License Law drier not apply Io an owner of 10 2 — PIERS
IERS I d Inspections
property who builds or improves thereon,and who does such work himself or through his
own employes,provided that such improvements are not mmnaed or nlremd for sale.If. 103 — UFERI
however me building or improvement is sold within one year of comPlefion,the owner.
builder will have the burden of proving that he em not Mud or improve for purpose of 10 4 — REBA'R
"I`"). 105 — ANCHOR BOLTS
b1,as owner of the property.am exclusively contracting with licensed convectors to
construct one,project(See.704.Business and Professions Calc:)The Contractor's Lb 106 — SEWER & WATER
Ilse law does not apply to an owner of property who Wilds or impm.ss daemon.and 202 — UNDERFLOOR PLUMBING
who contracts for such projects wi lh a contractor(s)licensed pursuant to the Contractor',
License Law. 203 - UNDERFLOOR MECHANICAL
❑l am exempt under Site ,R&PC for this mason 204 - UNDERFLOOR FRAME
205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATION LARATfbN
I hereby affirm under penalty of perjury one of the following declaration,: 3 01 - ROUGH PLUMBING
❑lnaseanawwmmnmin.cenifixmoreamsemmxlr-msumrawarteracampcn- 302 - TUB & OR SHOWER
radon,m pmmem ter by seuron nIa Lir the Labor code,ter the perrormanse or the 3 03 - ROUGH MECHANICAL
weak for which Of.pvman is issued. 304 - ROUGH ELECTRICAL
❑1 have and will maintain Worker's compensation Insurance,az required by Section
37TH of me Labor code for the performance of fire work for which this remit is issued. 3 05 — FRAME
My Workers CompensationInsuancecannotandPolicynumberam: 306 — HOLDOWNS
Carrier: PaliNa: 307 - INSULATION
CERTIFICATE OF EXEMPTIONN FROM WORKERS
COMPENSATION INSURANCE 308 - SHEETROCK
least)
(This xenon need net he completed iftM permit is for one hundred dollars(S 100) 309 - EXTERIOR LATH
ni310 - INTERIOR LATH
employ certify the er thein any mann of otic work for wubM1 chis permit is &,acd.om shell nm
Lawo California.on in any manner so atm Mcumc subject lM Workers'Compensation 311 — SCRATCH COAT
Law of caliraDam 313 — ROOF NAIL
Applicant
NGnCETOAPPLICANT:If.ater making this CenBleamofExemption.you mouw 501 - FINAL ELECTRICAL ENERGY
became$Object to the Worker's Compensation provisions of the Labor Code.you in=
]Z forthwith comply with such provisions or this Perm it shall W duceared revoked, 502 — FINAL PLUMBING ENERGY
z CONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL ENERGY
I hereby affirm that there is a construction lending agency for the Performance Of 504 - FINAL BUILDING ENERGY
z > thnder's urwhich lhis permllisissued(Scc.JU9T,Cis.C.) 505 — FINAL ELECTRICAL
3.130 L.nda's Nam.
I<naers aaere:z
J z 506 — GAS TEST
J 1certify that 1have read this
tyandcounAnd surainnthe aboveinformationis 507 - FINAL PLUMBING
y f-' coned 1 agrte m comply with all city and county ordinances and sum laws relating m '
Z)U building comsrreion.and herebyeuthodm mVmxnfativcs of this city to enter upon the — FIN MEC ICAL
'have-mentioned rrorcny for inspection purposes.
y (We)agree to save.indemnify and ke.p harmless the City of Cope Lino against 0 9 F I
h liabilities.judgments,costs and expenses which may in any way accmcagairstsaidCity 5 NG /
J Z in consequence Lir me srantmg of Permit.
^ APPLICANT U ERSTAN AN ILL MPLY WITH ALL NsON'/POINT Issued by: 5 C WORKS Date
SOURCE RE ATI. /?Lr� �1/—Lia/ O—�
si alar fAppilaeUtd feman �� I Data Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle havardous reameal
defined by the,Cupenom Municipal Cods.Chapter 9.12,and the healon and Safety
.Section 35533(,)7 All roofs shall be inspected prior to an roofing material being❑Yes ❑Nu p P Y g g installed.
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
milha4ardous air conminants dc fined by Inc Bay Arca Air Qualify Management all new materials for inspection.
District'ia'ie? uaz
E3 Yes ❑NO
1 have read be hmallous materials acquirements under Chapter 6.95 of the Calder.
nice Wilds&SafayCal Secuum 25505.25537 and 25534.1 understand that if lM Wilding
does no ly nave a tenant,that if is my expansibility an only IW map t of do
require hichmust Nmet poor to issuance oraCcNhcateofOccup cat. Signature of Applicant Date
Owner aauthorivedagent DateAll roof coverings to be Class "B" or better