03040104 CITY OF CUPEWfINOji
BUILDING DIVISION PERMIT �CON�TTRACTQR INF,O,RMAT,-'
N,
BUILDING ADDRESS: PERMIT NO03040104 3040104
427 AITRNIMA 1A
OWNER'S NAME: FERMR LSSUE DATE
4'12
24WHITECT/ENGINEER: BUILDING
E: SANITARY NO. CONTROL N0.
C !/',tl/a, BLDG PERMIT INFO
,tl�Gaa ELECT PLUMB MECH
0 0 0 0
Q0, LICENSED I am
mONIRd under previsions
DECLARATION
1ion7 affirm Nat1amftheBdumkrprovisionsofChapter 9 S'ccnma Job Description
with s«dan7rytD)moimxion3ortheBusiness.na praresoonx Code.and yh«n.i, .
5'q= LicenllseClaassmderreC�' C_ Lie.g C ADD 487 SQ. FT. /WINDOW UPGRADE
s o Dau: /L7�_ECi Comtmcur y e4 CONTRACTOR: CELTIC CONSTRUCTION (06/24/03)
5£ f 21 ARCHITECTS iITECI'S DECLARA ION
C< 1 understand my plans shall k..it as Indio.mwNs
>yU
.OG Licensed Professional
S Oat I am exempt
firm
DECLARATION
y 1 mono affirm that 11. cxcmpt s an Ne Conlncmrs e:Any c Law for the
00 which re maznn.(Section IIDL3,Business and Profession,Code:Any city or county
<m whichitsiss,apcalso re cores uct,altir.Oe
ire for such
Permits or repair anytWmum _
°zy
prior to issuance.also myuimsthe applicam for such Permit rile asigned statement
£ < that he is ficenecd pursuant to the provisions or the Contractor's I-Jecom Law(Charter 9 Sq. FL Floor Area Valu%ipS000
F�Fe (commencing with Section 7")or Division 3 or be Business and Professions Code)or
i $
that he is exempt therefore and Ne burs for the alleged exemption.Any violin on of .a,p
Section 7031.5 by any applicant for a Permit subjects the applicant m a civil Penalty or 3 41,2415 Itltber0 0 Occupancy Type
not more than five hundred dollars(s500). P Y YP
❑1.as...af,hc progeny,or my employees with wages u Ock mile composition,
will do she work,and rm simulate is not intended or offered for sale(Ser.7044.Business
and Professions Crdc:The Contractor's License law docs not apply to an owner of 101 - FOUNDATIONy d Inspections
propenimve
y who builds or pros thereon,and who doeasuch work himself ordtrough his
own employees.Provided res such improtemcnts..at intended m ci ered forsak.If, 102 — PIERS
however,the Wilding or improvement is said within one year or completion.the marver-
Wolder will hove the Wrdcm of proving mat he did not mild or improve far purpose or 103 — UFER
sale
❑1.u owner of the propeny,am exclusively contracting with licensed contractor to 104 — REBAR
consumer the project(See 7044,Business and professions Code:)The Coameto's U. 105 — ANCHOR BOLTS
come law does not apply in an owner of propeny who Wilds or improve themes,and 106 — SEWER & WATER
who contracts for such projects with a commercial licensed pursuant she Contractors
01 am L.exempt 202 — UNDERFLOOR PLUMBING
❑lam eaemps under Sec. ,B&PCfo Ni,reuon
203 — UNDERFLOOR MECHANICAL
owmen Data . 204 — UNDERFLOOR FRAME
WORKER'S COMPENSATION DECLARATION
thereby affirm under Finally ofNduryaronrthe following decorations: 205 - UNDERFLOOR INSULATION
an ad will maintain is CaruficacofConsent inset(-insure far worker'.Compcm- 301 — ROUGH PLUMBING
n,u provided for by Section 37110 of she Labor Codc,for the pcsfornance of the 302 - TUB & OR SHOWER
for have
iliaparmiin issued.ED 303 - ROUGH MECHANICAL
I nave and will maintain he pert a Comgofthe w Wouramar,rkfm who u required pen by Section
neo of me Later Code.rte the perfarman.a arthe work rte whom nisi pemnBis issued. � 304 - ROUGH ELECTRICAL
My Workre,Campeuation Iutunnec carrier end Policy rumh.r ase: 3 05 — FRAME
Carrier. Put icy No.:
CERTIFICATE OF EXEMMON MOM WORKERS' 306 — HOLDOWNS
COMPENSATION INSURANCE 307 — INSULATION
to lcsv)('�sis..Ii...it notIse completed if the permit is for one hundred dollars IS IM) 308 — SHEETROCK
1 ecru! 0.1 in the B,rmance of the for which this 309 — EXTERIOR LATH
r gen at permit is issued.I shall not
employ anyperson ins inner.talo become subject to the WorkeKCompensation 310 INTERIOR LATH
laws or Cal o ice.
Applicant 1r t. % t 311 — SCRATCH COAT
NOTICE'1 1�SPPLICANT:Ir,olio make lMs c ifieate or Exemption. 313 - ROOF NAIL
become subject to me Workers Cmarame lion provisions or tk labor Codc you must
zo roMwithenmpywdnawnprovisimmorm pnmhhallxd.m.d �kd. 501 — FINAL ELECTRICAL ENERGY
to CONSTRUCTION LENDING AGENCY 502 — FINAL PLUMBING ENERGY
F
I hereby affirm Oat ther,is a cormorclion lending agency lot the performance of 503 — FINAL MECHANICAL ENERGY
fY> the work for which this permit is issued(Sec.3097,Cie C,)
0. 0 Lenders Name 504 — FINAL BUILDING ENERGY
UZ tndr,Addrss 505 — FINAL ELECTRICAL
V Q I terrify ren I have mad mix application and sue that and
some information is
!L F^ cercus.I agree to comply with all city and county eminences anJ state law,relaxing m 506 — GAS TEST
C)V Wilding construction,and hereby maroon,representatives of this city to a Wupan the FIN PLUMB G
ahovcmentioned propeny rot impactors purposes.
F a
(We)egmc w eve,indemnify and k ep her le th City of Cup nine against 0$ F I AL
to liabilities,judgmcnts.costs and ex mus
which may in any way accroc against mid City
U Z in consequence of the granting oflhksPermit. Issued b 5
APPLICANT NDERSTANDS A D WILL COMPLY WITH ALL NONPOINT y;5 ING Date
SOUR'cc LATIpNS.
/ W Re-roofs PUBLIC W RK
ignvure of ApplicaHAZARDO Dae
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Willy the
sen!mumbuilding occupant mom or handle havalith amaerial
as def Sed by re Cupertino Municipal Codc,Chepmr 9.12,and the Hcallh and Safety
Calc.Schon 25532(x)?
❑re, 0 N All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or(mare Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hanrdnus air contaminanta u dc0ncd by she Bay Arca Air Quality Management all new materials for inspection.
t?
IF ❑Yes ON.
I have mad she WraNlmsmakrials reyuiromcmts under Chapter 6.95 of the Califon
Z;
HwWffi afctyCodc. vets 25N15,25533and25534.1undcrsuntlmasifmc Wilding
dmea'n dy have e¢ I.Nat it is my mspenchilily m notify the Cup.,or the
/ �m.uw%hyil�the �tPn aoraceniE.aearaaPam.y. Signature of Applicant Dale
Owner or aurorived.,cnr Dale All roof coverings to be Class "B" or better
A