02100017 CITY OF CUPFRTINO �, h-
RUUAINO DIVISION PERMIT CONTNNN�RACTOR INFORMATION '
B1
ILpI9b&2141 HOMESTEAD RD PERMI'rN(02100017
364Y1(SAMARITAN UNITED METHODIS APPLICATIJVIN ,719�� 2002
PIIONFi: SANITARY NO. // vv C01,71401,NO.
ARCHG`ECT/ENGINEIiR: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
FF I hereby a0irm that I em licensed un)ececccr bovisiom of Chapter 9(cOr mencin O CSC�1
�iul wi Isenio ]1 BafDivi....a. it On 13 dProfessionus Ceade.midmy licenay TI- -ADD EXHA5II L 'kiA`tI'H$
.jy wfull of def s Ci d2U,up
z Ogj? License Cl' I.ic.N
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,_?-�L Gen num D� —,.. "kt�f, PII�IAIvaE®
F-�� � ` ARCIIIILCTS DE� RAl'IO�k-N
s$am� lundcrstand my plans shallMaaJ as Puhhc recnNs
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Licensed 11 18
2002
OWNER-BUILDER DECLARATION
u<I 1 hereby affirm that I am exempt from the Contractor's License Law or the p� $4000
m S°O following mason.(Section 7031.5.Business and Professions Cole:Any city or county BUILDING
e da m which requires a Permit to com niel,alar,improve,demolish,or repair any structure
1O- prior to its issuance,also requires the applicantfor such Permit o file a signeJnaterienl
that he is licensed pursuant In the provisions of NC COnlractor's Licence law(Chapter 9 Valuation
rc�m (commencing with Section 7000)of Division Jnf the Business and Professions Cnde)or
y that he is exempt therefrom and On,basis for the alleged exemption.Any violation of
Section 7031.5 by any oppliconl for a permit subjects the applicant to a civil penally(ifPN-N Occupancy
not more than Five hundred delta.($50)(f). 102 - PIERS p y Type
0 I,as owner of the property,or my employees with wages u their sale compensation,
Wilt do the work,end the structure is not intended or offered for sale(Sec.]PW,Business and Professions Code:The Conuacurs s License Law does not apply to an owner of 104 - REBAR Required Inspections
Property who builds or improves thereon,and who does such work himself ur through his
own employees.provided Nat such improwmcnts are not intended or offered for sale.If, 105 - ANCHOR BOLTS
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden Of proving Nal he did not build Or improve for purpose of 106 - SEWER & WATER
ream')' 202 - UNDERFLOOR PLUMBING
01,as owner of the property,am exclusively contracting with licenscd contractors to 203 - UNDERFLOOR MECHANICAL
construct the project(See.71134.Boniness and Professional Code:)The Comments.Li-
conese Law does not apply to an n%net of property who builds or improws thereon,and 204 - UNDERFLOOR FRAME
Liccense Laawu for such projects with acommnor(s7lmenad pursuammmre
e C^mct^ri' 205 — UNDERFLOOR INSULATION
I am exempt under Seo. ,B&PC for this reason 301 - ROUGH PLUMBING
mer Data 302 - TUB & OR SHOWER
WORKERS COMPENSATIONDECLARATION 303 - ROUGH MECHANICAL
I hereby affirm under penalty of perjury one of the following declarations: 304 — ROUGH ELECTRICAL
71I have and will maintain a Certificate of consent to alf-insure for Worker's Compen- 305 - FRAME
cation,as provided for by Section 37W of the labor Code,for the performance of the
work for which this Permit is issued. 3 06 — HOLDOWNS
❑1 have and will maintain Worker's Compensation Insurance,ax required by Section 3 07 - INSULATION
31181 of the Labor Code,for the Performance of the work for which this Permit is Issued,
My orker's Compensation insurance carrier and Policy num her are: 308 — SHEETROCK
ier:ALL uA-3r ZAPS pesri-�a�ii�c��y,���1�sgqLLxs�:C2°�-02d�5 309 - EXTERIOR LATH
CERTIFICCOMPF.NSATIONIINSURA CEORKERS' 310 - INTERIOR LATH
Missectionneed not hecompletedifthe permit is far one hundred dallau($f(g)) 311 - SCRATCH COAT
or Ices.)
313 - ROOF NAIL
1 certify Nat in the arformenco of the work for which this Permit is issued,l shall net 5 01 - FINAL ELECTRICAL ENERGY
employ any Person in any manner m as m u
become subject the Workers'Compensation
Laws of California.Date 502 - FINAL PLUMBING ENERGY
Applicant
NOTICE TO APPLICANT:IL alter making this Cenilicam of Exemption,youshouW 503 - FINAL MECHANICAL ENERGY
become subject to the Workers Compensation provisions of the labor Code,you must 504 - FINAL BUILDING ENERGY
OO forthwith comply with such provisions or this Permit shall he deemed mooted.
z 505 - FINAL ELECTRICAL
CONSTRUCTION LENDING AGENCY
7) CONSTRUCTION
hereby amm m ^mw
rat there is a eedon lending agency for the Performance of 506 — GAS TEST
a > heWork for which this Kerns isissued(Sec.3091,Cie.C.)
f1l lender's Name 507 - FINAL PLUMBING
Q
z Leader'sAddmas 508 - FINAL MECHANICAL
U O 1 ter ify Out I have read this applicstant and sate thin the be.ialminiflon is 509 - FINAL GRADE
[A F correct.l agree to comply with all city and county ordinances and state laws relating to
O U building construction,and herehyauthorizeaPrcaemativesofthis city toenter afro c 5 FINAL PLANNING
above-mentioned property for inspection purposes.
> y (We)agree tolow,indemnify and keep harmlessthe City OfCupcnimi incl 14 FIN W RKS
HUJ liabilities.judgments,costs and expenses which may in any way aci against said City
mcmdo Y��
U APPLIC SITe NDERrnANDStAND W LL COMPLY WITH ALI,NON-POINT Issued by: Date /
SOU RE ,A'
Re-roofs
Snm of Applicant(Cnmrmum Date
HAZARDOUS MA R1 LS DISCLOSURE Type of Roof
Will the applicant of future buildin upant store or handle heartland;material
'tied by the CupeNno Municipal C ,Chapter 9.12,and the Health and Safety
de.Section 25532(m'I
❑res All roofs shall be inspected prior to an roofingmaterial being installed.
r-,
Will the applicant or furore buildingoecupxnt use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit owundous aircomaminaons as defined by the Bay Area Air Quality Managetnenl all new materials for inspection.
District'!
❑Yes
(have calmehamrdausmamrialsmquimmenuunderCMpmr695o(NeCalifor-
niallcalth& afety Cak,Stttiom25N)5,25533 end 255}1.1 undersand lhmiflM building
does net only a coram,mat it is s nsibility to notify[be nruPant of me
requiry at whic a i. canoe m^tae panty. Signature of Applicant Date
°- - All roof coverings to be Class "B" or better
rumborircd agent Dam