03080115 C 'I'Y Ol:CUPER'PINp
BUILDING DIVISION PERMIT 4&,CRONI'"CT,OR,INFORMkTION
OUILPING ADDRESS: CLEAR OAK DESIGNS PERMIT N0.03080115
R7Q`7r)NT ]OR
R'SNAME: 1723 B ROGERS AVE PERMFPMUEDATE
(408) 436-5448 SANITARY NO. CONTROL NO.
ARCIIITECI'/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
I" LICENSED CONTRACTOR'S DECLARATION
;n 1 hereby affirm that 1 am licensed under prnvi,lmrs of Chapter9(commencing lob Description
?�W wile Section] qnf Division Jofthc Buxipcz�and Pmfc inns Crvlc.and gyl' csc �l�It
+ sorrel f L YO �_7/ ADD 25 SQ. FT. /KITCHEN Fll� 14VEASTM,
Liccnn ` Li
F O 04
at, r —
3 A h.IsoTSDE ATION JUN [��4
I and at d plans anall m uMlc me rds U
LL Licensed P anal
_res cn OWNER-BUIL -R DECLARATION t� �t y�
aS I here y affirm that 1 am exempt from the Contractor's License Law for the BUILADiimu
0 o following reason.(Section]11]1.5.Business and Professions Calc:Any city or county
<$ff which acquires a permit to consumer,alter,improve,demolish,or repair any structure
oiov rtiss
prioo its um ance,also requires the applicant for such permit file a aignedsunl
tcmc
< mat he is licensed pursuant to the provisions nrthe Contractor's Licirse Law(cnaptery Sq. Ft. Floor Area Valuation
(commencing with Section 7()(U)of Division J or the Business and Professions Cmic)or
2�$ that he is exempt therefrom and the basis for the alleged exemption.Any violation of 32637031 . (10
Section 7131.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(S501)). P Y YP
1,as owner of the progeny,or my employees with wages as their sole compensation,
will do the work.and the structure is not intended or offend for sale(See.]OSa,Business iui _
And Pnfcssions Code:The Contractors License Law docs not apply to an owner of d Inspections
property who builds or improves thereon,and who does such work himself or through his 102 - PIERS'
own employees.provided that Such improvements tic not intended Or offered for sale.If. 103 — UFER
however.the building or improvement is old within am year of completion,the owner-
Wilde,will have the burden or moving mat be,aid ret wild or improve ter punto«or 10 4 — REBAR
sale.).E. 105 — ANCHOR BOLTS
❑ E.As owner or ct property,.Business ext contrasting Ccd licensed eC Contractor's
m
const Law docmjot Apply an
fproperty
who Niids
Ode:)Troves dreparS and 1O6 — SEWER & WATER
cense Wwdoesnmapplr roan ith aofpmpertywho seders improves Nanton.and 202 - UNDERFLOOR PLUMBING
who contracts for such projects with a contractor(s)licensed pursuant to me Contractor's
LieenseLiw. 203 - UNDERFLOOR MECHANICAL
❑ I am exempt under Sec. .B&PC for this reason
204 - UNDERFLOOR FRAME
Da205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION
Ihereby Arms on&,prally of ,j.,mic of the following declarations: 301 - ROUGH PLUMBING
Im
haw and will maiin aceniRcme of Consent 1. elfiexum fee workers Carron- 302 — TUB & OR SHOWER
amino,as provided for by Section 37W of the law,Code,for the pcorommne.Of the 3 03 - ROUGH MECHANICAL
work for which Nis memos,is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3 04 - ROUGH ELECTRICAL
37M of the labor Code,for the performance of the work for which this pe it iq esma. 3 05 - FRAME
My Work pro:adonln5ummeea«ierand Ppreygym 5 II��.T/ 306 — HOLDOWNS
r70 ERTIFI ATE OF c��kNNyyCAWOrare:
"� CERTIFICATEOF EXEMPnON.l+NOM WO KER e 307 — INSULATION
COMPENSATION INSURANCE 308 — S'HEETROCK
less.)('ITissectinn mcamtbicomplmcd innc mcrmdishmorchandredmillars($100) 309 — EXTERIOR HATH
or
I«mfy Or,in he o foorm o,Of the work for which this permit is ward,I Snag am 310 - INTERIOR LATH
employ say pare in any manner so az to become subject o the workers Compensation 311 — SCRATCH COAT
Laws.(California Date
Applicant 313 - ROOF NAIL
NOric E TO APPLICANT.Ir,over making this Cortifoam of Eno prion,you should 501 - FINAL ELECTRICAL ENERGY
become subject m the Worker's Compensation provisions of the Labor Code,you must
OZ mrthwiIII comply With such prevision:nrthis Permit small nedeemed«voked. 502 - FINAL PLUMBING ENERGY
? g CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
I hereby affirm chat them is a construction lending agency tar the perrurmanco of 504 - FINAL BUILDING ENERGY
Od > the work for which this permit is moral(Sec.3C97.Civ.C.)
i p
Lend er'IName 505 - FINAL ELECTRICAL
= Z naerSAaamaS 506 - GAS TEST
U 0 1 certify that 1 have mad this application and scam that the above information is 507 - FINAL PLUMBING
ry, correct.1 agree to comply with all city and county ordinances and state laws relating to
building construction,and hereby amhorim mp sicautivcs or Nis city to enmroom
n Nc
V ahovcmentiunedpropertyforimpletionpurposes. FINA4, VNG' L
(We)agree th save.indcmni Iy and keep harmless the City of Cupcnino against 0 9 FIN
F" N liabi l Iles,judgments.coats and expenses which may in any way scenic against said City 5
U ZAPPLICANT`UNDERSTANDf tAN TWILL COMPLY WITH ALL NON-POINT Issued by:5 C WORKS Date U
S R REGULATIONS.
_roofs OF PLYWOOD NAIL
Re-m c ofApplicanvCont or Dam 6_Q3 - OOF BATTENS
HA:, OUSMATERIALSDISCLOSURE Type ofR 4 - ROOF IN
Will me amplieant or wn wilding oceupant slue nr handle harartlum material
,-de(cd by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
QY n 255]2(x)? - All roofs shall be inspected prior to any roofing material being installed.
Will alto applicant or future building occupant ore e If a roof is installed without first obtaining an inspection, I agree to remove
pp 6 p equipment or devices which
'it haimm us air contaminants m defined by the Bay Arca Air Quality Management all new materials for inspection.
isuict?
❑Yes r rvu
I have read me haaNausmatinals requimmcam under Chapter 6.95 of me Colum,
malcalNXSafetycede,Secuom2 5J3 and 255Jq.1unecrsunJNairthe willing
docs not currently won a truant. a it u y re5pominilily W tM Ponta"uof the
whiehmu5twm ,dart ,SSaalleaoIsee f tear er Signature of Applicant Date
All roof coverings to be Class "B"or better
Ow aulwrimdagcm Z Doc