03030156 (2) CITY OF CUPERTINO �"�`�" � '`a§• '��
BUILDING DIVISION PERMIT r CONTRACTORINFO hIATIQIN..
BUILD Q5815.RICARDO RD. ALVAND CONSTRUCTION PERMITr4o.03030156
PERMUEDATE
D EOSHE MENDELSEN 10413 TORRE AVE. IT15S
04/03/20033
011111KE; (408) 781-7620 SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�0o LICENSED CONTRACTOR'S DECLARATION Job Description
z<0 1 hereby Affirm Nu 1 am licensed op
under provisions or Chapter 9(commencing
with Section 7").f Division 3 or the Eastman,end Proposal..Code.and my license Is
In full force and cRen.
i'gi
License Class Lm.g REVISION--PIERS/FOOTING--IN HOUSE USE ONLY
qqqqqq Gas—Commlut
3ARCHITECT'S DECLARATION NO NEW PERMIT ISSUED, ORIG. #02070062
i gi undcrwnd my ptsnuhsil W used As public mcnrN
,w
u. Liccnted Pmfcuionel C
OWNER-BUILDER a DECLARATION Contractors
// \
.�a f 1 hereby.Bios NAI 1 1. excerpt from Ne Cnmons;Co Licence Lew for the \O
p O following Inuoa Permian 7 o tr Business and Rofcumns Code:Any city or manly
$ which requite•permit to Anna;the eller.Improve,demolish,mea sir any stawture
tement prior to its lietm race,at aut t. a movishms.faut forsuch 1h.C.M ermluoics.igncd autemenl
qq <
(commencing
ening stip.rnuntmNcpmvWs.ofof ftB rams lJw.ei�w(CMpler9 Sq. F[. Floor Area lar igI11
N thammcnc osowilheerefrom and
Divbionr the
NCeged exemption.
Any
CMc)or \)
� Nu W 6 excerpt therefrom and Ne bub for Uu alleged emmpUon.Any violation of
Section 7031.5 by any applicant for a pewit subjects the applicant M a civil penally of APN Number Occupilmy Type
not more than five hundred dollars($500).
❑l,u ownuortheproperty,mmyemploym with wages utheirsrdemmpenaatiw. '15601 054 nn
will do the work and Neawcwre I.not intended oronemd forsam(Sec.7044,Business
and Profusions Cade:The Contractors Limnae Law does not apply to An owner or Required Inspections
property who Wilds or improves thermn.and who doeuuch workhimulfm through his 101 - FOUNDATION
Own employee,proWded that such Improwmmta are not intended muttered fmsale If,
however.the building or improvement is sold within one year of completion.the owrcr• 102 — PIERS
Wilder will haw the burden of proving Wt he did ant Wild m improve for purpose of 103 - UFER
talc.).
1.as Owner of the property,am exclusively convecting with licensed convectors to 104 - REBAR
construct the project(Sec.7644,Business and Prolusions Coda)The Contractors U. 105 — ANCHOR BOLTS
come Law time not apply M an owner of property who Wilds or Improve Utemm.and,
who contracts for such pmjeeu with a contnmor(0 licensed pursuant M the Contractors 106 - SEWER & WATER
`I`IasoLaw'
lamer under Sm. BAPC(m We 202 - UNDERFLOOR PLUMBING
, mann
r Dow 203 - UNDERFLOOR MECHANICAL
WORKERS COMPENSATIONECI.a DDN 204 - UNDERFLOOR FRAME
I hereby strive under Nulty of perjury oro or be mllowln{decimations: 205 — UNDERFLOOR INSULATION
El I have and will maintain aCertiOcate of Comm to selFhtaum fm Worker's Coupon. 301 — ROUGH PLUMBING
ration,As provided for by Section 37W of the Iabm Code.for the performance of the
work for which this permit is issued. 302 TUB & OR SHOWER
0 I have and will maintain Worker's Compensation Insurance,As required by Section 303 - ROUGH MECHANICAL
3700 of the labor Code,for the performance of the wort for which this peril is Wold. 3O4 — ROUGH ELECTRICAL
My Werkara ComlwcuUon Insum of carrier and Polity number Art:
Corder. Policy Na: 305 - FRAME
CERTIFICATE OF EXEMPTION FROM WORKERS' 306 - HOLDOWNS
COMPENSATION INSURANCE
(This section need not W completed If the permit b M)Formic hundred dollara(S I307 — INSULATION
or less.) 308 - SHEETROCK
1 certify that in the performance of the work for which this permit is Issued,I aha.not 3 0 9 — EXTERIOR LATH
employ any permm in my mannorm As to become subject to the workers'Compensation 310 — INTERIOR LATH
Lemur Csiiraraia.Dau
Applicant 311 - SCRATCH COAT
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
Wceme subject to the Workers Compensation prodsln.of the labor Code,YOU mut 313 - ROOF NAIL
ZZ
forthwith Comply with Such provisions or this permit Mail to deemed"Oked. 501 — FINAL ELECTRICAL ENERGY
[. pat CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
.r Iheehy affirm the,than iuconetraction lending agency for the perf.manmof
C > the work for which this pewhlsbanter(Sm.3097.Ch,C.) 503 - FINAL MECHANICAL ENERGY
O o derdee s Addrev Aame 504 - FINAL BUILDING ENERGY
Len
Z)z
UO lcenifythat Ihow mad this application And autethat the AWwinfmmad.Is 505 - FINAL ELECTRICAL
lgm conect.I agree to comply with all city and county ordinances end vete laws elating to 5 6 = GAS TEST
O building convection,and hereby mehatim representatives or this city to enter tram tits
lg7 ehavcmendonedpmpenyfor WpemUonpurposea 0 FI%LPLWUMBTMNG
(We)sgme to saw,indemnify and keep harmless the city of Cupertino AI 0 8 FI AL
limilhiel,judgments,costs and expenses which may In my way ammo against said City to
T71
U 7 In concequcnce of Ne gaming oft srewiL
l7 APPLICANT D ND=LLL COMPLY WITH ALL NON-POINT Issued by: 5 Date
SOURCE ULATIO
ITMr
Re-roofs 514 INAL PUBLIC WORKS
mO ApplienUContranor Dau
HAZARDOUS MATERIALS DISCLOSURE Type of RAP 2 - ROOF PLYWOOD NAIL
Will the applicant Or future building Omupanumm rehandle havurdous material 603 - ROOF BATTENS
As dented by Ute Cupertino Municipal Code.Chapter 9.13.and the Health and Safety ^ —^�^^_,.,_^ g
code.section 15531U)7 All roofs S e Ins CR rl o al' IiJO(iObrdl'N'Yti"�'aterial bei. Installed.
❑Ye apo
Will the applicant Or future Wilding Occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
cmh haaAtdam air conitminante As defined by the Bay Area Air Quality Management all new materials for inspection.
Monet? 1,
❑Yu [No
I hevc mW Ne haurda/auua---maudais mquimmenu under Chapwr6.93of Ne Celifor-
iiaHcelNgtSatrtyCodc,Section]SN)5,15533 and1 34.1 undcruond NuifUte Wilding
does not cuncnlly hew A mum Ir my mall",,,
e hilhyn notify 1W—Or.,m the
mqu munuwhmh mmmimrto —Cntrnme.te.roecupancy. Signature of Applicant Date
Owner Ned All roof coverings to be Class"B"or better