03010069 (4) CITY OF CUPERTINO
Buu.owc mvlsroN PERMIT CONT ' 'ICTORwINFORMATIONss,'
nuB.D1NGADDRE.9s: NOR-CAL CONSTRUCTION PERMrr NO.
10112 SENATE WY 0301006
ERSNAMG: 5255 STEVENS CREEK BLVD #1 8PPLICATION SUB DATE
NINA FELSHTINER 01/10/2003
PIIONE: (408) 295-0813 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINITR: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�00 LICENSED CONTRACFOR'S DECLARATION Job Descri
..r F 1 hereby affirm Ihm 1 am licensed under provisions of Chapter 9(enmmencing E[7
��S with Section? MB of Division 3 of the Business and ProfessionsCo
Cle,and my below is A
infnumrreandeffect. RELOCATE DOORS & CLOSE OPEN
q, License CIee, Lie.a
Dale T'SConDEL NATION JAN 2 2 2003
qq Ictor
1 understand my plARCHTECTS ans shall be vud as public re...us
:0yu
3 scd P
Liccnonessionul p ��
ILL0 U OWNER-BUILDER DECLARATION UILDI
ee a F 1 hereby affirm Nat 1 am exempt from the Contractors License Law for the
w—OO following reason.(Section 7031.5.Business and Professions Code:Any city or county
e K$ which mquims a permit to construct.aIle,,improve,demolish,An Icpsir any nronum
'o— pnnr In its issuance,alsomquines the applicant lorsuch permit to file a signed statement
�2�2< that he is licensed pursuant to the provisions of the Contramnr'.s License LAW(Chapter 9 Sq. Ft. Floor Area $1 i9'410ation
F$ (cnmmcnci ng with Senior7(XM))nf Division 3of the Business and Professions Code)Or
... that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 0031.5 by any applicant for a permit subjects the applicant o a civil penalty of Occupancy Type
not more than five hundred dollars($500).
❑ h es owner of the impend,or my employees with wago M their sole comansatinn.
will do the work,and Ne stwuna is not intended proffered far sale(Sec.7044,Business
and Professions Code:The Correctors License Law does not apply to an owner of 102 - PIERS equired Inspections
properly who builds or improves Hereon,and whadas such work himulfor through his
own employees.provided that such improvements arc not intended nroRcted for rule.If, 103 — UFER
however,Are building or improvemenl is sold within one year ofcompletion,Are owner. 104 — REBAR
builder will have the burden of proving that he did not build or improve for purpose of
ale.). 105 - ANCHOR BOLTS
I u owner of the property.am eulusively contracting with licensed cantrsel..to 106 - SEWER & WATER
Co. n the project(Sec.7044,Busimss and Professions Code:)The Contractors Li-
censeLaw does not apply to an owmr of property who Wilds or improves diemon.and, 202 - UNDERFLOOR PLUMBING
Who conflicts for such projects with a conhano(s)licensed pursuant to the Contractor's
License Law. 203 — UNDERFLOOR MECHANICAL
❑lamexemwnde B&PCmnhisreason 204 - UNDERFLOOR FRAME
er / Date�..6-1 205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION 301 - ROUGH PLUMBING
s IhembyalErmunder Penalty ofperjuryaeofthe following declmnias 302 — TUB & OR SHOWER
❑lhave privicl (a,by Section
37()of Labor
Code.for forirOmmace of the 303 — ROUGH MECHANICAL
cation,ss providctl for by Scminn 3]11(1 of Ne IaMr Cade,for Ne annnnaac o!the i
wank for which this permit is issued. 304 - ROUGH ELECTRICAL
Ll 1 have and will nOmamo Wnrkcr's Compcnsnnn Insurance.as mquircd by Section 3 05 - FRAME
370)of the Labor Code,for the performance of the work for which this farmul is issued.
My w oke Compensation Insurance canner and306 — HOLDOWNS
Policy N'. 307 - INSULATION
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 308 - SHEETROCK
(This scedanerd nm be completed B m
the Permit is hundred dollars 310)) 309 — EXTERIOR LATH
n leas) 310 - INTERIOR LATH
1 cenify that in the pmlitmance of the work for which this permit is is sued,I shill net 311 - SCRATCH COAT
employ any person in any manner so as to become subject as the Workcri Compensation
Lawsofcarmmia.Date 313 - ROOF NAIL
Applicant
NOTICE TO APPLICANT:It.after making this Cenificate of Exemption.you should 501 — FINAL ELECTRICAL ENERGY
bemmc subject to the Workers Compensation provisions of the labor Craft,you muss 502 - FINAL PLUMBING ENERGY
O Z forthwith comply with such provisions lir this permit shall he decmcd mvokcd.
z CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
tr iN+ lhemhyam,.Nmthem isaconstuedonlending agency lot the performance of 504 - FINAL BUILDING ENERGY
Ix > Ihcwolkfit,which this permitisissued(See 3097,Civ.C.) 505 - FINAL ELECTRICAL
W5 Lender's Namc
az Under'sAddress 506 - GAS TEST
V O 1 cenify Nm 1 have read this application and safe that the above infomtatiun is 507 - FINAL PLUMBING
G. Fcmmn.I agree to comply with all city and county ordinances and sate laws relating I.
building conswnion,and hereby aumnriac rcprcunafivex of this city memer u{vm the 5 FINAL MECHANICAL
0W
above-mention
ed propend forinspectionpurposes. O9 — FIN
(We)agree ro save,or inspection
keep harmless the City of Cupertino against
r„f y liabilities.judgment,costs and expenses which may in any way aceme againstsaid City 5 N G f�
V z lin consequence of the grand ng of this permit. !/
F-f APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT Issued by5 1 WORKS Date
SOURCE .GUL.ATl NS.
Re-roofs
356,6107
o HAZARDOUS
Dam
IIAZARDOUS MATERIALS DISCLOSURE Type of Roof
Willapplicant(it fumes building occupanterreor handle ousmateriel
y a
x droned by the Cuninu Municipal Code,Chapter 9.12,and Ne ficalfh and Safety
e,Section Y25532arr
x No All roofs shall be inspected prior to any roofing material being installed.
1 Will the applicant ant future building occupant sexcquipmcnt orJcviccs which If a roof is installed without first obtaining an inspection, I agree to remove
crit hamrdnus air conmntimm..daGned by the Bay Arca Air Quality Management all new materials for inspection.
District? rr ,
❑Yes ,QIN.
1 have lead one huranfim,,materials mqui,cmenta under Chapter 6.95 of An,Calif.,
lin I Icuhh&3JICIy Gsle,Sections 25515,25533 and25534,I understand Out if Nc holding
it,.,nal cunt ly have a tenant,Nat it is my msponvimlity to ratify I'lakccupial Of the
rcyviremc hie -mmpnmmissuanceofac""cam.6af. . Signature of Applicant Date
1" a
Dale All roof coverings to be Class "B" or better
�. Owner auth vcd agent