02110096 CITY OF CUPERTINO
BUILDING DIVISION PERMITCONTRAC-TOR
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> Ps . PPY DR STARRETT & ASSOCIATES INC PERMITNO2110096
hF$lld&E7 RONALD Y AND PAULINE 2395 S BASCOM AVE APPLICA-T11s 1u4T.2002
PHONE: (408) 44S-2040 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
Met,00 LICENSED CONTRACTOR'S DECLARATION
�F I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing BATHRM/BASEMENIPb;��T�iti9iS `L
With Section 7000)of Division 3nf NCB si send Pnsfe�ons S)I.and my license is
6 in full"end cif Q' 'J
o=qs Dataas
sto
sto
Lice C or — FINALED
F— off' ARCH( 'CTS DECLA A ION
EVU
no ,a a 1 pub eemds JUN 0 5 2003
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HLLOg I. cn J r...lseinmil
g OWNER-BUILDERCI. RATION
1 hcrchy affirm that 1 am exempt fro the 'omrannrs License Law for the 10000
m—p 0 following reason.(Section 7031.5.Business an
I'd Cuts:Any city or county el,', ^f •�
a n$ which requires a permit m construct,alter,improve,demolish,or repair any structure w • D• N
_Z< poor to its issuance.also requires the applicant Im such Permit o Ne a signed statemem
££ that he is licensed purstanuo the provisions of rhe Cuntmctnr's Lt..U.(Chapter 9 3*2Wf@6AA&G Valuation
C�m (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y $ that he is exempt therefrom and she basis for be alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of 1 U APIqN Occupancy Type
not more than fin hundred dollars($500). 102 — PIERS
p y yp
❑I,as owner of the property.or my employees with wages as their sole compensation, UPER
will do the work,and the structo.is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Convenors License law does not apply to an owner of 104 — REBAR Required Inspections
property who builds or improves themon,and whodoes such work himulfor through his
Own employees.provided that such improvements am not intended orofmad for sale.If, 105 — ANCHOR BOLTS
however.the building or improvement is sold within mm year ofcomplition,the owner. lO6 — SEWER & WATER
builder will have the burden of proving that he did not build or improve for purpose of
sate')' 202 - UNDERFLOOR PLUMBING
I,as Owner of the property,am exclusively contracting with licensed contractors to 203 - UNDERFLOOR MECHANICAL
construct the project(Sec.7W,Business and professions Code:)The Contractor's Li.
cense law aces nm apply to an an,of property who builds or improve.thereon,and, 204 — UNDERFLOOR FRAME
Lwho censclawu for such projects withaconvacmr(A Licensed to the Contractor', 205 - UNDERFLOOR INSULATION
❑I am exempt under Sec. ,B&PC for this reason 301 - ROUGH PLUMBING
Offer Data 302 - TUB & OR SHOWER
WORKER'S COMPENSATION DECLARATION 303 - ROUGH MECHANICAL
I hereby affirm under penalty of perjury one of the(allowing declarations: 304 — ROUGH ELECTRICAL
[7 ]have and will maintain a Certificate of Conaem to self-insure for Workers Compere 3O5 — FRAME
sation,ss provided for by Section 3700 of the labor Code,for the performance of the
work 0r which this permit is issued. 306 — HOLDOWNS
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section 307 - INSULATION
37M of the labor Code,for the performance of Ne work for which this permit is issued.
My Works s rum c sari r/lnsumn limimand�Iia n bar 308 - SHEETROCK
carrier: IA.91G poedyM.an / 309 - EXTERIOR LATH
CERTIFICATE
COMPENSATION IINSURANCE
ON FROM ORKERS' 310 — INTERIOR LATH
Orissecriun neednot Marmpleed drum,Permit islnrone hundreddollon($100) 311 - SCRATCH COAT
less) 313 - ROOF NAIL
1 certify that in the Performance of the work for which this Permit is issued,I shall not 501 - FINAL ELECTRICAL ENERGY
employ any Parma in any manner m as in become subject to the Workers'Cumpensation
Laws of California.Data 502 - FINAL PLUMBING ENERGY
Applicant
NOTICE TO APPLICANT:11.mile,making this Certificate of Exemption,you should 503 - FINAL MECHANICAL ENERGY
become subject to the Worker'a Compensation provisions of the Labor Calc,you must 504 - FINAL BUILDING ENERGY
OO forthwith comply with sue a provisions or this permh.ahat l b,deemed revoked,
z CONS'TRUCfIONLEN DING AGENCY 505 - FINAL ELECTRICAL
F- = IMehyallirmcon Ncreisacunstrvnionlending agency lnrmeperfurmanceof 506 - GAS TEST
a ?
five workFor Which this permitisissued(Sec.3097,Civ.C.) 507 - FINAL PLUMBING
la1 Q Uncl a Name
a Lender:Address 508 - FINAL MECHANICAL
U0 1 certify mat 1 have mad thirty and coup and sine that the above information. g is 509 — FINAL GRADE
f0U curtdct.lagree tocomply
,andhwith
rebymityandcepresty ntaiivesofand ata¢lawsrupingm 5 FINAL PLANNING Vv/
0 building conswctinn,and hcrchy authnrio rcprescnmtivcs nl this eiry reamer upon the a nhnvc-ince) ned agree
rindemify anoyer,purposes. 14 — FIN BLIC WORKS
(We)ogre,to navy,or Insp icy and keep harmless de City of Cupertino againxt
Do) liabilities,judgments,costs and expenses which may in any way acme against said City
V z in conscy ec abbe granting of this permit.
rti APPLIC NDERSTANDS AND L COMPLY WITH ALL NO -PO T Issued by: Date
SOUR E TIONS. /v'
/ Re-roofs
S' re of Applierm"Comonor
I IAZARDOUS MATERIA.S DI CLOSURE Type of Roof
Will N,applicam ar fumrc building«c an bore or handle havnNuus material
u defined by the Cupertino Municipal Code, pmt 9.12,and the Health and Surety
Jc, [3y,s 25532(a)'! Na All roofs shall be inspected prior to any roofing material being installed.
Will the applicant nr mrc building Occupant use cyuipmem or devices which If a roof is installed without first obtaining an inspection, I agree to remove
mit b t mcmis air cumamina ts az JcfincJ by tM Bay Arca Air Quality Management all new materials for inspection.
District?
El yes No
I have mad Ne ha'ordo' ma crisis rcyuircments order Chapter 6.95 of the Cali for _
niullc.th 'army Cralc,Sn;tio ns255f15,23511 and 25534.1unocamnJ thmifthc huilJing r
does no u n y haw u mount,mar it' y resPOnsihility m nndly tM ayeyyyyyyPPPpPPant of the -
fe afire a mGGsthcmcrpoO o umcco aCcmfi mOfOccoyyr[�� ignature of Applicant Date
04,Xmahnoodagent Dare All roof coverings to be Class"B" or better
s