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CITY OF CUPERTINO
BUILDING DIVISION PERMIT ,,ii,.,
CtNTRA�Td �NFOVIAT�
BUILDING ADDRESS:
PERMIT NO.
03050094
OWNER'S NAME:
PERMIT ISSUE DATE
05/20/2003
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
License Class Lic. a
UPGRADE/REPAIR FOUNDATION
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
$ 4V8l8ion
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
,h DN HhT #T��; O O
3 6i�
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sole compensation,
101-
FOUND �Id
will do the work and thestructureisnotintendedorofferedforsalc(Sec.7044,Business
and Professions Code: The Contractor's License Law does not apply to an owner of
Inspections
property who builds or improves thereon, and who does such work himself or through his
10 2
— PIERS
own employees, provided that such improvements are not intended or offered for salt. If,
103
- OF ER
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 of
104
— RE BAR
sal`')'
105
— ANCHOR BOLTS
Y1, as owner of the property, am exclusively contracting with licensed contractors to
oostmct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li.
106
- SEWER & WATER
terse Law does not apply to an owner of property who builds or improves thereon, and .
202
— UNDERFLOOR PLUMBING
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
Lieenme
203
— UNDERFLOOR MECHANICAL
❑ [ errs exempt ugder Sec. , B & P C for this reason
r
``'„
204
- UNDERFLOOR FRAME
Owne s'v" — "ate�S,-
WORKER'S COMP SATION DECLARATION
205
— UNDERFLOOR INSULATION
I hereby affirm under penalty df perjury one of the following declarations:
301
— ROUGH PLUMBING
❑ I have and will maintain a Certificate of Consent to self -insure for Workcr s Compen-
302
- TUB & OR SHOWER
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
303
— ROUGH ME CHAN I CAL
work for which this permit is issued.
304
— ROUGH ELECTRICAL
F11 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor code, for the performance of the work for which this permit is issued.
3 05
- FRAME
My Worker's Compensation Insurance carrier and Policy number are:
306
- HOLDOWN.S,
Carrier: Policy FROM
CERTIFICATE OF EXEMPTION FROM WORKERS'
307
— INSULATION
COMPENSATION INSURANCE
308
— SHEETROCK
(Thissectionticcd not be completed if the permit is for one hundred dollars ($100)
309
— EXTERIOR LATH
or less.)
310
— INTERIOR LATH
I certify that in the perfo ante of the work for which this permit is issued. I shall not
employ any person anner so as to become suWect to 5hc Workcrs' Compensation
311
— SCRATCH COAT
Laws of Califomiln. tc
Appli t ` ,n. .. ,.'
313
501
— ROOF NAIL
— F I NAL ELECTRICAL ENERGY
NOTIC APPLICANT: If, aftei making this Certificate of Exemption, you should
become subject to the Worker's CoYnpensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
502
- F I NAL PLUMBING ENERGY
t CONSTRUCTION LENDING AGENCY
503
- F I NAL ME CHAN I CAL ENERGY
1 hereby affirm that there is a construction lending agency for the performance of
504
_ FINAL BUILDING ENERGY
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
505
506
- F I NAL ELECTRICAL
— GAS TEST
�
Lender's Address
I 1 certify that I have read this application and state that the above information is
507
— FINAL PLUMBING
correct- I agree to comply with ill city and county ordinancesiveof and state laws relating to
'-..-
building construction, and hereby authorise representatives of this city to enter upon the
FIN MEC CAL
above-mentioned property for inspection purposes.
0 9
F I
t (We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in anyway accrue against said City
WORKS Date ,t
SOURCE REGULATIONS.
Re -roofs
Type of Roof
/
r
tore of Applicant/Contractor [[r Dale
HAZARDOUS MATE, IALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
All roofs shall be
inspected prior to any roofing material being installed.
C3 Yes 5fNo
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminans as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes kNo
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
rq which must be met prior to issuance of a reale °f Oct: angy.
Signature of Applicant
Date
,ments
% / _>el"•
Z _
All roof coverings to be Class "B" or better
Ov>n r or`authorizcd agent r` Date