02050025uOCZ
F Z�
yju
z
C
yFL
�sQ
0
.COQ
u3 } —
00C
0
c
X LL
V.
i_Z>
C (— C
C
CITYBUILDING DMSSIIONv® PERS
CONT -CTO NFORA.U* e
—
BUILDING ADDRESS:
7557 BOLLINGER RD
WESTWOOD
CONSTRUCTION INC
.
PERMITN 82050025
650 WINCHESTER BLV
APPLICAT10SiJBDAT�2OO2
U / V b
PHONE:
(408)395-9231
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
U CJ C.'7 L__J
i. LICENSED CONTRACTOR'S DECLARATION
i hereby affirm that I am licensed under provisions of Chapter 9 (commencing
ADD
pl�eg g�,
2 8 5 SQ FT &A1 e?1 ti1�TH REMODEL
with Section 7000) of Division 3 of the Business and Professions Code, and my license
. .
I. Is in full force and effect. 9 G,
License Class Lic. p aC. tl
Date Commctor
CHLTECT'S DECLA 0'
1 understand my plans shall be used as public records ,OAec,
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5. Business and Professions Code: Any city or county
$200000
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the,applicam for such permit to file a signed statement
__ . _. _ ........ ..
that hi'Ji'licerised pursuant. to chi provisions of rhe Contractors License Law (Chapter 9
i P
( (commencing. wlth;$tmUon Z000)�of Division 3 of the Business Professions Code)
3 �6r:FI��
�, `�� ���
Valuation
Eor thai he is exernpt'therefrorn and the basis for the alleged exemption. Any violation
ofSection 7031:5 by any applicant fora permit subjects the applicant -to a civil penalty--
sof not more than five hundred dollars ($500).
101t1PAl 1�ttnultJiMDAT I ON
Occupancy Type
171, as owner of the property, or my employees with wages as their sole compensation,
102
— PIERS
-'wi1P:d'o ifie'work; aod'lhe structure is not"frifencled or ofTered'forsale (Sec: 7044;
Business and Professions Code: The Contractor's License Law does not apply to an
M—
ER,
Required Inspections • -
owner of property Who builds or improves thereon, and who does such work himself
104
— RE BAR
or through his own employees. providedathat such improvements are not intended or
offered for sale. If, however, the building or tmprovnent is sold within one year of
—ANCHOR BOLTS' "• "'
' compfetion, the owner -builder will have the burden of proving that he did not )wild or
improve for purpose of sale.).
106
— SEWER & WATER
_...__....._......_........_................................._.............._........
C 0 1, os;°wner of the property, am exclusively contracting with licensed contractors to
_.... 202
.._ .UNDERFLOOR PLUMBING..._..:
construct the project (Sec. 7044: Business and Professions Code:) The Contractor's
203
— UNDERFLOOR MECHANICAL.,..
License Law does not apply to an owner of property who builds or improves thereon,
and,who.conuacts..focsuch .projects.with a.mntractor(s)-licensed pursuant.to the
....... _..........20..4.....-.
"
UNDERFLOOR... FRAME.:__ ..•...................-
col am a rs License Law.
❑ 1 am ,.,..
t' ' � '� ''
xempt,under Sec,. —.11'k P C for this reason
205
_...._..._.... _
— UNDERFLOOR - INSULATION
owner �.� '.... Date .: ...
301
— ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION
302
— TUB & OR SHOWER
1 hereby affirm under penalty of perjory'one of the following declarations:
303
— ROUGH MECHAN I CAL
have'and will maintain a Certificate of Consent to self -insure for worker's
304
— ROUGH ELECTRICAL
mpensation, as provided for by Section 3700 of the Labor Code. for the
3 05
— FRAME
rformance of the work for which this permit is issued.,
Xhave and will maintain Workers Compensaiion Ine, "'required required by. Section
306
— HOLDOWNS
3700 of the Labor Code, for the performance of the work'for which this permit is
307
— INSULATION
issued. My Workers Compensation Insurance carrier. and Policy number are:
CarrierYWV16 / Vi°W5 ' •'PolicyNo'.:,, .,
7/3 163 .72
3 0 8
— SHEETROCK -' ...... ....,.e ..... ...... ._...
;' i'"CERTIFICATION OF EXEMPTION FROM WORKERS`-' , .
3 09 ;'
_ _ EXTERIOR LATH
:.......;...Co.MPENSAIIQN.INSURANCE..:::.` :..° '.....:-. ...
3.1-0--,
...INTERIOR. LATH_____.... ...._..........._ .. _.. _. .
i5 section n«a not be completed if the permit is for one hundred dollars
311
— • SCRATCH COAT : -
(S 100) or less.)
.,
. 3,13...
-..,.ROOF :NAIL
: , .'1 certify that in the performance of lie* ivbik for which this permit is issued,,
501
— FINAL ELECTRICAL `'ENERGY'
shall not m
employ any person in any manner so'as to become subject to the. Workers'
Compensation'Laws of Califomia.,Date
5 0 2
— FINAL PLUMBING ENERGY
.Applicant -' :. :: ,.
NOTICE To APPLICANT:,$ after making this certificate of Exemption. you should
503
...
— F I NAL ME CHAN I CAL ENERGY
become subject to the Workers Compensation provisions of the Labor Code, you must
foithwith'comply with sash provisions or this permit shall be deemed revoked.
504
— F• I NAL BUILDING ENERGY
^.CONSTRUCTION LENDING. AGENCY .. '
505
- -FINAL ELECTRICAL
..
f hereby affirm that [here is e, construetion lending agency for Elie performance
506
— GAS TEST
Of Ih! Wark'for which Ih15 tort is Issued (SGC:'3097. CIY; C.)' -
-Le:derslvame.._I,..:.._<..,..;._.,•:..:..... •....:._.. ... ............:.:..:
..... .... 507
— -FINAL PLUMBING .._
Lenders Address ••'
• - - "
508
— FINAL MECHANICAL --
I certify that I have read this application and state that the above information is
509
— FINAL GRADE
correct. 1 agree to comply with all city.arid county,ordinances and state laws relating
to building mnsutictien'mid hereby authorize representatives of this city to enter upon
510
— FINAL PLANNING
the above-mentioned property. for inspection purposes. ,
(We)'agree'to save. indeinnify and keep' hamdess„the City of Cuperiino against
514
— FINAL PUBLIC WORKS
liabilities, judgments,. costs and expenses which may in anyway eccrue against said
•.
,
City in consequence of the -granting of this Permit-
V°PL _N'DERS OMP Ly WITH ALL NO\ -PO AT
S E
I
Issued by:
6�
Date —/
�, !� �,
ign?ture'ofApplieant7C6jtumctoi':' ata-*
”, HAZARDOUS MATERIALS blsCLOSURE' ".'
Re -roofs
'w'.the'applicant or future 6uildin;'occupant.store ondler haliaz8rdous material
ljrpe Of ROOF
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
-
• '..
Code: Section 25532(a),9 ' ...:' ;{ e '
oYes: "'
All roofs shall
be inspected prior to any roofing material.being installed.
.. Will the applicant or future building occupant use equipment or devices whichIf
a roof is installed without first obtaining an inspection;• I� agree to remove
emit haiardousair contaminants as defined by the Bay Area Air Quality Management
District' '
a new_ materials
or inspection Applicant understands and wL cum with
1 comply
No .•.
all tregulations...
non-point
.. .
source
' 1 have"read the, hazardous materials requirements under `Chapter -6.95 of the
Califomia Heilth & Safety Code, Sections 25505;-25533 and 25534. 1 understand that
if die building does not currently have a tenant: that it -is my responsibility to notify the
occupant f the re "ements which muss be mer prior, to issuance of a Certificate of
Oec ... �� , .
�
Signature of Applicant Date
�
All roof coverings to be Class `B" or better
O.wnerorauthp cd.agent Vie..