03040083 CITY OF CUPERTINO
BUILDING DIVISION PERMIT i CONTRACTORANFORMATION:
BUILDING ADDRESS: N P CONSTRUCTION PERMIT NO 03040083
11 5'� KPNTWOOD AIT
OWNER'S NAME: 416 MARTIL WY PERMIT LSSUE DATE
(408) 942-0520 SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
tlLDG ELECT PLUMB MECH
I_� !
I00 LICENSED CONTRACIOR'S DECLARATION Jo DCSCrI fi
C Z on
N 1 hereby affair that I am licensed under provisions of CM1aPler Y(commencing P �/r�I
[ w withn form id,f uDivision3of NC Basincss and Professions CnJc.andmyliccnscis u
nmmuroeawerm" ADD 1024 SQ . FT. /REMODEL
'�n Dmt,License Class Can
DEC 0 2003
t_p Datc COS DECLARATION _
L Q'� ARCIeITECTS DECLARATION
IunticrstanJ my plans she llMuseJ as public recnrJs
s0g Licensed Pnrfcsnna
sil pl�n�n �Qmrt
OWNER-BUILDER DECLARATION LVJ (S ,I q
y'y a Y 1 hereby affirm mtJ I am exempt from the Contractors License Law 1'nr the �+
p o fallowing rcasnn.(Section 7131.5,Business and Prnfaminns Code:Any city pr county
S m E which requires a Petmii in construct,alter,improve,demolish,or repairany structure
prior it)its issuance,also requires the applicamer such permit to file a signed statement
Z< mat he is licensed pursuant to the PrOvirimal Of the Catamount's License Law(Chapter 9 Sq. Fl. Floor Area Valuation
1-0 (commending with Section 7Wgof Division 3 Of the B minesa and Professions Codd or
i W E that he is e.empt therefrom and me basis for the alleged exemption.Any mamma m of 35931021 . 00
Section 9031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of APN Number Occupancy Type
not more than five hundred dollars($510). P Y YP
❑i,as owner of the progeny,or my employees with wages as their sole compensation,
will do the work,and die structure is not intended or offered for sale(Sec.7044,Business 101 - d Inspections
and Professions Code:The Commuter's License Law Joey not apply to an owner of p
property who builds or improves human,and who does such work himself or through his 102 — PIERS
own employees,provided that such improvements are not intended or offered for sale.if. 103 - UFER
however,the building or improvement is sold within one year of completion,the owner
builder will have the burden of proving that he did not build or improve for purpose or 104 — REBAR
ale'). 105 — ANCHOR BOLTS
1,as Owner of me Property,am Inclusively contracting with licensed canuactors to -
nstmcl the project(Sec.704,BusloCO.".
cv and Professions Code:)The COnctur's Li. 106 SEWER & WATER
cense Law does not apply an owner of property who builds or improves(human,and 202 — UNDERFLOOR PLUMBING
who contracts for such projects with a centractoT(s)licensed pursuant to the Contractor's
Lfdense Law. _ 203 - UNDERFLOOR MECHANICAL
❑lam eacmpt cr See t ,Bk PCfnr this reason
204 - UNDERFLOOR FRAME
205 — UNDERFLOOR INSULATION
w � WORKER'S�MPENSATION DECLA N —
Ihembyamrmunderpenahyarpe�aryaneanneraBawingeecmrath,ns: 301 — ROUGH PLUMBING
I have ad will Worker's C..,n- 302 - TUB & OR SHOWER
sation,as provided for by section 3700 of the Labor code,for the performance of the 3 0 3 - ROUGH MECHANICAL
wor01 farhave
and this permvis issued. 304 — ROUGH ELECTRICAL
❑1 have and will maintain he Performance
work
for hi h inquired by Section
nmorthe Labor cote,for me peRormandear me warvar wmdn this Front is 305 - FRAME
My Workers Compensation Insurance carrier and Pm icy number am: 306 — HOLDOWNS
Cartier: Pal icy No.: _
CERTIFICATE OF F.XEM Pf10N FROM WORKERS' 307 - INSULATION
COMPENSATION INSURANCE 308 — SHEETROCK
This sudden need not le completed if The Farm it is rte one hundred dollars 1$100) 309 - EXTERIOR LATH
I curd.7 310 - INTERIOR LATH
e certify flat in the performance of the work for which this theretoreissued.l shall not 311 — SCRATCH COAT
employ any person in any manner an u m become subject m the Workers'Compensation
Applicalicamaws of nt raroia.Dam 313 — ROOF NAIL
NOTICE TO APPLICANT:I L after Maki ng this Card licaneof Escmption,you should 501 — FINAL ELECTRICAL ENERGY
become subject to the Worker's Compe.action Provisions of the Lahnr Cnde,you mus
.Jz ToethwithcomplywithsuchprovisionsnnhinFarmitshaBlredeemedmiardd. 502 - FINAL PLUMBING ENERGY
zCONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL ENERGY
[-+ 4 I hereby affirm that there is a construction lending agency for the performance of 504 — FINAL BUILDING ENERGY
ai z the work for which this permit is issued(Sec.3(07,Civ.C.)
IL] q Lenders Name 505 — FINAL ELECTRICAL
LenJer's Address
q Z 506 — GAS TEST
V O I certify that 1 have with
thisapplication
and
and state that and
above information is 507 — FINAL PLUMBING
C) (~ building I agree ct comply with all city and county ordinances of and state laws relining e
building eonsuucRom,and herebyactinauthorizerepresentatives of this city to enter upon the perR
�C.) above-mentioned progeny for inspection proposes. FINAJL MECjTN
AL
F 0.Wi
(We)agree to save,iWcmnify and keep harmless me City of Cupertino against 9 F I
co, *U
liabilities,judgments,costs and expenses which may in any way accmc against said City 5 aUZ in consequence or the granting or this permit. Issuedb 507APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT y; ORKS Da
SOURCE R ATION
Re-roofs
Sig w c of ApplicanVCime, te
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store nr handle Invitation;material
az rtin
defined by the Cupeo Municipal Coda,Chapter 9.12,and the Health and Safety
Cade.Section 25532(e)? All roofs shall be inspected prior to any roofing material being installed.
FI Yes T110
Will the applicant or future building occupant use equipment dr devices which If a roof is installed without first obtaining an inspection,I agree to remove
.alt hazardous air contaminants m dcfned by the Bay Area Air Quality Management
District? all new materials for inspection.
a
❑Yes TNo
have mad the herarders materials requirements under Chapter 6.95 of the Cali for
nia Heuhh A SNcty Calc,Scctians 25NI5,255J3 any 255]4.1 undcrsmnd that if the
Militia,
does not curtently have a tenant,mm it is my rdsponxihility to norily the oentpant of the
require mn most rte met prior to issuance of a Ccnmcam Of Occupancy. Signature of Applicant Date
C
owner umari..ddagen, Dale All roof coverings to he Class "B" or better