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CITOF CUPERTINO
Tt}R ATION'
CONTRe1CINFO
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
075 2A2ADRNA A-17
TERRY BROWN, GEN CONTRACTO
ERMITNo03080168
OWNER'S NAME:
BROWN TRRRY M RT AT,
14510 BIG
BASIN WY
PERMIT ISSUE DATE
E:
(408) 868-1640
SANITARY NO. ONTROL, NO.
C
ARCHITEC (ENGINEER: -
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSEDCONTRACTOR'SDECLARATION
Lm that
1 hereby that I em licensed under provisions of Chapter 9 (commencing
under
lob Description
P
with Section 0).r Division Sof the Business and Profcuiom Cotic, and mylicense is
in full force arta cffem.
ndefce
License Class Limp
. TI --ADD REAR STAIRWAY & DOOR
Date Contractor
ARCHITECTS DECLARATION
1 understand my plain shall M used as public records
-
%
Licensed Professional
DECLARATION
OWNER
/
-BUILDER
1 hereby affirm on 11. exempt from the Contractors License Any c Law for the
following mason. Permian 7(171.4 Business and Professions oe: Any tiny or manly
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h.
eller improve demolish. or repair ed urucwre
which requires a Permit re cores
for
prior In its issuance,also requires the applicant for ouchpctor's fins LAw(maNment
the t
pursuant to the Law(Chapmr9
Sq. F[. Floor Area
Va seat
(commencing With of Division of telt ustcmand Pro
eu and Professions Codi) or
(commencing with radion 7000) of Division J of the Alleged
Nal he is exempt Nemfrom and the buil for Du alleged exemption. Any violation of
35717043.00
Section 7031.5 by any applicant far a permit subjects the applicant to a civil penalty of
" "-"
-APN Number
-"'"-
Occupancy Type
P Y yP
not mare Nan Five hundred dollars ($500).
- - -- -
I, as owner of Ne property, or my employees with wages As their sole compensation,
will do Ne work, and the structure is not intended Or Offered (Or 3210 (Sec. 7044, Business
Profession, Code: The Convector's License Law
J.Ui-
AkAYAd Inspections
And does not apply to an owner of
property who builds or improves thereon, and whodoessuch work himself orfl rough his
10 2
- PIERS
own employees, provided that such improvements arc not intended oroRered formic, It.
103
- .UFER -
however, the building or improvement Is sold within one year of completion, the owner.
builder will have the burden of proving than he did not build or improve for pupou of
10 4
- REBAR
i1c')'
105
- ANCHOR BOLTS
❑ 1, as owner of the property, am exclusively contracting with m
106
. -...
- SEWER & WATER
construct doexnoct(Sec.oan wneroueopProfessionsCudo:3TheConvectorsLi
:) The Contractor's
wase Law tloesnoubpNtoan arofpropeny who or and
- 202
-' UNDERFLOOR PLUMBING
mimproves Connec
who contracts for such pmjeN with a contractoKa) licensed pursuanno the ConuadoM1
with sedator's
Len. Law.
203
- UNDERFLOOR MECHANICAL
esem oder Sec. B di P C Int}� a rc�on
n
*Bll
2 04
"- UNDERFLOOR FRAME
' ter � ^ !7i' / d
'WORKER'S COMPENSATION DEC ?'—r,
205
- -
- UNDERFLOOR INSULATION
IherebyaffnnunderPenaltyof perjury one of the following declarations:
301
- ROUGH PLUMBING
ave and will maintain a CeniOcau of Consent no self -insure for Warter2 Compcn.
302
-, TUB & OR SHOWER
A. u provided far by Section 3700 of the labor Coda, far the performance of the
3 03
- ROUGH - ME CHAN I CAL
W for which this Permit is tamed.
304
-' ROUGH ELECTRICAL
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
7700 of Ne Labor Cook. for Ne performance of Ne work for which this permit is Issued.
305
- FRAME
My Workers Compensation Insumncr c,Aicrand Policy number am:
306
-. HOLDOWNS .
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
307
- INSULATION
COMPENSATION INSURANCE
308
- SHEETROCK
(This section read nut he complewa if the permit is for no hundred dollars IS 100)
309
- EXTERIOR LATH
or
310
- INTERIOR LATH
I cent.)
employ certify Nut er the in any panne of Ne work for which this permit is issued, I ahall nut
311
- SCRATCH COAT
Lawso Cs1ifomninanymanncranulnbecomembjccuothcWodcrs'Compensation
Laws of California. Dow
Applicant
313
501
- ROOF NAIL
- FINAL ELECTRICAL ENERGY
NOTICE TO APPLICANT. If. after making this Ccniricare of Exemption. you should
become subject to the Worker's Compensation provisions of the Lehor Cade, you must
forthwith comply with such provisions or this permit shall A, deemed mvoked.
502
- FINAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY
503
- FINAL MECHANICAL ENERGY
I hereby affirm that there is a construction lending agency l or the performance of
504
FINAL BUILDING ENERGY
A. work for which this permit is ended (Sec. 3097, Civ. C.)
Under, Name
505
506
- FINAL ELECTRICAL
- GAS TEST
UnderaAddress
1 certify that 1 have read this application and state that the about information is
507
- FINAL PLUMBING
correct. I agree no comply with all city and county ordinances and stem laws relating to
building construction, and hereby soNorim representatives or this city to enter upon the
FIN MEC CAL
shove -mentioned property for inspection purposes.
indemnify
0 9
F I
(We) agree to save, and keep harmless the City of Cupertino againan
Iiabililiea.judgments, costs and eapensa which may in any way accrue agar^tot aeitl City
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NG
in consequence of Nc gmming or this permit.
APPLIC UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: 5
C WORKS Dat
OUR E NATIONS.
Re -roofs
Type of Roof
- d
Signature of ApplicanUComracmr Deu
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant in future building oecupml atom or handle hav4rdous material
As tle6ncd by the Cupenino Municipal, Code. Chapter 9.12, and the Health and Safety
Codc, Sermon 25332(,)?
All roofs shall be inspected to any roofing material being installed.
❑ Yes Cho
prior
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
a'sardous air contaminants As defined by the Bay Arca Air Quality Management
all new materials
for inspection.
a?
❑Yes Y
1 have mad the havarzhms materials myuimments under Chapter 6.95 of the Califon
ria Herd" & Safety Cock, Sections 25X15, 25533 And 25534.1 umlemsnd Nat if the Wilding
does not currently have a tenant, Nat itis my responsibility to ^adfy oecupem of the
myuircmcn Most be me(p'rAn issuance oraCnlfcaa, myp,
Signature of Applicant
Date
Q
All roof coverings to be Class "B" or better
own m orixrd agent , wd