02070186 OF
CI BUILDI G DIIVISIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10525 DE ANZA BLVD US SHEET METAL 02O701�E86
FE6•sIZA PLAZA PARTNERS 380 TERRAINE ST APPLIc07ATION/29UB 33/2002
PHONE: SANITARY NO. CONTROL NO,
(408) 292-1314
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O O ARCHITECf/ENGINEER: g - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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,n= LICENSED CONTRACTOR'S DECLARATION lob Description
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G Z— 1 hertby affirm Nw 1 am licensed under previsions Profs of nsChapter Code.(commencing TI--KITCHEN UNGRADE
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with Nil tonllXM))ofDivision l of the Business and Professions Code.orb 0)Y titans
is in full fora end eff«t.
O ] Cleo Xa Date Contractor«i
a. ARCHITECT'S DECLARATION
I undemend my plans shall be used as public recants
OO Licensed Professional �� m m...s•c:�N �� r-'�� —�`
OWNER-BUILDER DECLARATION
rat I hereby affirm that 1 1. efrom the Losions C s License Law for the �_�_ y t s
(:Z 0 (allowing uman.(Section construct,
Business, ms, andimprove.
Professions Code:Any city structure county - ti] '. I 6 S�O
O which t its iuv a mems[to con mum aper,improve demolish,or repair any statement
`_ { I _
g�$ �pnw loin tuvattce.d u9utrc the aPPhcem fat such pemmno filar signed stammer -- - - --- `-- -- -
°• — Ina]hg ts I tablet]puimfaru 16 ye ptovisiom of the Canuactors License law(Chapt.9
(ao memm�gwiths«m-]1X10) fDivmronJoftheBugoessaodpro(ssionsCakl t. iD.A; ii3,51L' 1'-i_,,;_i�. V luat n
q
or Nat heI.eiempf thertfrdm sub itt
the basis for the elled axemption.Any violation '
-af not come 3L5 five
hundred
chnt fora 500), subjects Ne applicam m a civil pcndry
;of not mart thin five htindrN dollars fssoo). i lO1APNll'i90�ATION ''�� ' ��' Occupancy Type
❑1,.covam.fthe propertRor anima li me,with wag.as their sole compensation, 102
—will dm the work:and thrwuomu it.1 Intended or offered for'sole'(S«.-7044,' 10 3 - UFER Required Inspections
Ihnumis and]Professions Code:The Conti«mr'v License Low rias not apply to an fl p
owner of property Who builds or improves thereon,and who does such work himself 104_- REBAR _
or throat h his own employees,provided that such improvements are not intended or - ....
-offered or sole:ICur-bud r,rlwibuilding or improvementriofPn sold within one year of - - 10 S — ANCHOR BOLTS +`
improve far the owner-builder will have the buNen of proving that he did not build or
improve for purpose of,al ) 106 - SEWER & WATER
_. - _ -- -202 "'UNDERFLOOR" -PLUMBING _
— ._.
Ka,
u pwner of the progeny am e I seely cumroatmg n N licensede Coonan to
a
honeraw the pro,«t(s 1tw4 a ass andprtyw ob eoee)Thrcontrecror, 203 - UNDERFLOOR MECHANICAL,''
License Lew does not apply t. nj cis w of property who builds s improve,Hereon
and.who contracts far_such.Pmj«ts with a.aomrucmr(s),IfcensW.pursuant.m.me...... . ... __-.2.�tI___-_ UNDERFLOOR 'FRAME.__.-_..-
(_, m Caer,,unde LOW. ,
❑lora exemptuMerS«. B&PCforthisrtason 205 - UNDERFLOOR'INSULATION
O,vnee oRKER 'MEsSlffdFME AroN 301 - ROUGH PLUMBING
302 - TUB & OR SHOWER
- - I hareby affirm ander penalty of perjury,one of the following declaration,: 303 - ROUGH MECHANICAL
(` ❑ 1 have aad wn maintain a Certificate of Consent to self-insum for Workers 304 - ROUGH ELECTRICAL
Compensation, as
for by Section J700 of the Labor Code, for the
'perfommem of the work forwhich this permit is issued. 305 — FRAME
❑I have'and will'maimain Worker's Compensutlnn Insurance,as required by Section
306 - HOLDOWNS
37M of the
Labor Code,for the performance of the work for which this Perini,is
307 — INSULATION
m tied My Workers Compensait a Insurance clunrier and Policy umber are:
_ 31 i,"•.t 1.,-if^,p
policy
.. - _ .. '— " .. . ...
Cartrer PolcyNo' I-1 3. 309:I.�)t""RIOR , I' H*'
I iCERTIFICATION OF EXEMPTION FROM WOftKERSi -
..- COM...... ION,INSURANCE •;+- _—_-__31O'--:
"mi:sectkm hmclnor ate completed if permit is for one hundred dollars 311 '_'SCRATCH COAT , ..
ISIOo)or less.)
r•.', . .. . :. :•_- n -. i ._ —313 ROOF NAI-L.. .. _ ..
1 certify than in sup performance of tr i work for which this ct to the
issued;1 501 - FINAL ELE OTR I CAL"ENERGY
ihdl not employ any person in any manner b u m become subject to the Wnrkeri
Compensation Lawanf California.nice
;Applicant ' . .5 ._.
.02._.- FINAL -PLUMBING ENERGY._... .
. .. .. , - - .._..
NOTICE TO APPLICANT:If.after making this Cenifimm of Exemption,you should' 503 — FINAL MECHANICAL ENERGY
become subject to the Workers Compensation provisions of the Lubar Code,you most
O
fonnwtmcomplywit n hp r n, tht meant naubadminedrevoked, 504 - FINAL BUILDING ENERGY..,-.,.
CONSTRUCTION LENDING AGENCY - 805 — FINAL ELECTRICAL
1 hereby affirm that th e is a cont ellon lending agency for the Performance
of the work for which this permit it issued(sec._3191,Cie CJ 506 - GAS TEST
r>J q Leaders Name - ,.--_�..-._.... ..,---"----- -
'o 507 = FINAL PLUMBING
7 z I:ehder's Address• .
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I emify that I have sad this application and state thin the above information is 5 0 FINAL NAL MECHAN I CAL
coneci.I agree to comply with all city and county wdimxes and,cem laws mines 5 — INAL G E
to building construction.and hereby authorize repmxntatives of Nisciry incineration
�+,mgt .the above-mentioned property for inspection purposes.-, - _ 5 0 INAL P NG
p: ta. (We)'agrmlo"salve.indemnify and keep harmless the City ofCupeninoagainst 51 - INAL RKS
-V1 liabilities,judgments,costs and expenses which may in any way accme against mid
% 'U.7�. City in consequcnceo le ming of lh' ' t. ,
_ (APURICANTGUINOF OT- DS D I OMPLYWITHALLNO -POINT Issued by; Date
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mums ppb, V ontmclor, z Dam. Re-roofs
v -HAZARDOUS MATERIALS DISCLOSURE
. s definetl by the W II the epplicmtt w future buldmg bccupam smne w handle hezvdmis mamrib Type of Roof. ... .-..
Cupertino Municipal Cale Chapter 9.12 and the Health mad Safety '
'tide «son 25532(0) - -,.. . . I:, kry a,ai '.k: k: ' t .-•- - _...... ....
Dov.• ? - ' d . t_ ,j!- - All roofs.shall be inspected prior to any roofing.material being.installed. ._.-.. ..
•W
It the applicant ser fumy Wilding«cup nt use equipment or devices which If a roof is installed without first obtaining an inspection; I agree to remove
to
haewdous air coca minants as by the Bay Arca Air Quality Management
District? _ all new materials for inspection. Applicant understands and will comply,with
Gy. --[IN. all non-point source regulations.
I have mad the hazardous materials requirements under Chapter 6.95 of the
C4lifomiaHealth&Safety Code.Sminns 25505,25533 and 25534.1 understand that
if the budding does mmurrently have a tenant that it is my r.p nabilay to amity the
occupant of the requiremen hie sur n be t r' r m iss n e of s Certificate of
Oc panty,
^ Signature of Applicant Date
or as natio d¢gem All roof coverings to be Class"B"or betteract' ,
-. . . .:'u. .. - . ..._..- . . . . . . . OFFICE .... .. -.. . _... .. _. . . .