02090194 CITY OF CUPFRTINO ,�
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUILPI 6k2DB-HOMESTEAD RD BLACH CONSTRUCTION COMPAN 1'1'RMITN®2090194
�E:SAMARITAN UNITED METHOD S1650 LAFAYETTE ST APPLICATION�I/BnQt�I2002
PHONE: 4 0 8 2 4 4-710 0 SANITARY NO. !! --'' CONTROL NO.
ARCI11 rECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
Piopp LICENSED CONBACIOR'S DECLARATION
I hereby afford that I am licensed under provisions of Chapter 9(commencing REV I S I ON--I NIi�USeEcr� NLY
with Section hkk))of Division 3 ofthe Basilicas and Professions Cee ,and my license is
inf.11formandeffect. ORIGINAL #VqLEW PERMIT ISSUED
,ctn? License Class Lic.N
Ila¢ I understand my plans shall be used ametpublicrecords
ARCHITECTSDECIARATION
JAN 1 0 2003
U
do W LLO Laccnscd Profexsimal
OWNER-BUILDER DECLARATION
u<Y 1 hereby atlirm that 1 am exempt from the Contracmds License Law file the BUILDING
wd S:p O following reason.(Section 1831.5,Business and Professions Code:Any city or county
w%� which requires a Permit to construct.alter,improve.demolish,Or repair any mrucmre O
FZ< poor to its issuance,also requires the applicant lorsuch permit to file a sigocdstatement
x that he is licensed pursuant to the provisions of the Contractor's LicenseLaw(Charon,9 Sq. Ft. Floor Area Valuation
SFO (commencing with Second 7")of Division 3 of be Business and Professions Code)in
Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of 3
Section 703 L5 by any applicant for aPenn it subjects the applicant m a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(55011). 101 — FOUNDATION
❑L as ownerof the property,or my employees with wages as their sale compensation, ±132
will Jo the work,and to structure is not intended or offered for sale(Sec.]DW,Business
and Professions Code:The Conmetor's License law does not apply to an owner of 103 - UFER Required Inspections
property who builds or improves thercun,and who does such work himself or through his
own employees,presided that such improvements arc not intended or offered for aele.If, 104 — REBAR
however,One building or improvement is sold within one year of completion,the owner. lO5 — ANCHOR BOLTS
builder will have the burden of proving that he did not Wild or improve for purpose of
ale) 106 - SEWER & WATER
01,as owner of One progeny am exclusively contracting with licensed condracmre to 202 - UNDERFLOOR PLUMBING
construct the project(See.I(,M,Business and Professions Code:)The Contractor's Li-
nselawdoesnotappiymanownerofpropenywhohuddsorimprovesthereon,and. 203 - UNDERFLOOR MECHANICAL
who summers for such projects with a conditions)licensed punuanuo the Contractor's
License Law. 204 - UNDERFLOOR FRAME
I am exempt under See. ,B&P C forthismason 205 - UNDERFLOOR INSULATION
ter Date 301 - ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION 302 - TUB & OR SHOWER
I hereby alarm under penalty of perjury one of the following declarations: 303 — ROUGH MECHANICAL
❑1 have and will maintain a Certificate of Consentto sel6lnsum for worker'a Compere 304 — ROUGH ELECTRICALsation,a provided for by Section Than of the labor Code,for the performance of the
work for which this permit is issued. 3055 — FRAME
❑1 have and will maintain Workers Compensation Insurance,as required by Section 3 06 - HOLDOWNS
3700 of the Vlror Code,for the performance of she work for which this permit is issued
My Workers Compensation lnsumnee carrier and Policy number am: 307 - INSULATION
Carrom: Policy N.: 308 - SHEETROCK
CLRTIFIC [ON FROM
WORKERS'
COMPENSATONINSURA CE309 — EXTERIOR LATH
(This seelionneed nut be completed if list permit is forms,hundred dullars(SIN)) 310 - INTERIOR LATH
orleaa.) 311 - SCRATCH COAT
I certify that in the perlinmance of the work for which this permit is issued,I shall not 313 - ROOF NAIL
employ any perum in any manner so as In become subject In the Workers'Compensation
Laws of California.Date 501 - FINAL ELECTRICAL ENERGY
Appf,am
NOTICE TO APPLICANT.If,af¢r making this C,nifcaaof Exemption,you should 502 - FINAL PLUMBING ENERGY
become subject to the Worker's Compensation provisions of the Labor Cane,you must 503 - FINAL MECHANICAL ENERGY
O Z forthwith comply with such provisions or this Knott shall M deemed revoked.
z CONSTRUCTION LENDING AGENCY 504 - FINAL BUILDING ENERGY
IhemhyaRrmthat then,her inearmundImiingagencyIn,sheperformove if 505 - FINAL ELECTRICAL
x > the work for which this permit isissu,d(See,309'I,Cis.C.l 506 - GAS TEST
LenJcr's
w A Lendcr' Address
sNamc 507 - FINAL PLUMBING
11
U O 1 cenify that 1 have read this appli,mion and state that the shout inhumation is 508 - FINAL MECHANICAL
L4 — correct.I agree to comply with all city and county ordinances and state laws relwing or 5"FINAL GRADE
O showngeddiondtlooand I inspctinerepreunmtives mf thiscitymenter upon the050 ahnvcmcoionuJprofeny ion,andheribyautinin,repree. WWO
ow (We)agree m save,indemnify and keep harmless the City of Cupertino againstV, liabilities,judgments,costs and expenses which may in any way accre againstsaidCity 5RKS
UZ in consequence of the grading of this permit.
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of Appli,aante
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will rbc applicant ror mfMuni Municipal
Co occupant tore or handle Health
mammy
IdineJ io the Cupertino Municipal CnJe,Chapter 9.12,and the HcaIN and Safety
Ic,Section 255711x)?40 All roofs shall be inspected prior to an roofing material being Installed.
❑ves ED No P P � Y g g
Will the applicant or future building occupant use equipment ser devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hasmdous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
Dyes El No
1 have mad the loomil usmar,nals requirements under Chapter 6.95 of the Cali for
ilia l health&Safety Code,Sectors 355115,25533 and 25511.1 undersand don if the building
does not currently have a tenant.that it is my res sensibility to nod fy be m eopant of the
requirements which must le mel prior to issuance of a Certificate of Occupancy. Signature of Applicant Date
Owner or authorized agent Dale All roof coverings to be Class"B" or better