03040044 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ,EONTRACTOB,�INFUtMATaIUN `
But1.Dlra3g50s N TANTAU AVE DPR CONSTRUCTION INC PEaMIrNo.03040044
UE DATE
OWN'It'$jgA�•1�ER PERMANENTE 1450 VETERANS BLV � IT�04/08/2003
1CHl SANITARY N0, CONTROL NO.
(650) 474-1450
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
=0C LICENSED CONTRACTOR'S DECLARATION toy IOb DescriptionOn iJ 1 hereby affirm that I me licensed under provisions m'Chapter 9(commencing
with Section Ofkl ofDividon 3 ofthe Bud mol Professions Code,md my license is
in full force ageem- ,tel 59 9 3 q10
Lkense Cl Lie.# 30 DAY TEMP PERMIT/EXPIRES 05/09/03
Z Dom/ 4 R a cmu mise A
ARCHIjjCTS DFCNALATION ORIG. #03020072
%a I understand my plans shall be used as public records '
D U
G Licensed pndessional
OWNER-BUILDER DECLARATION
I hereby atfim that I am exempt from the Contactors License law for the Igmoorary Permit
D O following reason.(Section 7031.5,Business and Professions Code:Any city re county
$ which requires a permit hr construct.eller,improve,demolish,or repolr any mueture
'^ prior to Its issuance,also rectums he applicant for such permit to rile a signed statement Valuation
8 That he is licensed pursuant to the provisions of the Contractor's Umm Law(Chapter 9
azp (commencing with Section 7000)of Division 3 of to Buslnces and Profusions Code)or Contractor and/or Owner a see too
a that he Is exempt therefrom and the huis for the alleged exemption.My vialation or
smiles
nmetha.5byuryapplWntfm spemitsubjeeu the applicant to acivilpcnalty of re�Eet for eorrectin addido c6*ihi!y Type
ret more Nan five hundred daltnr a per
❑I,uorvnu of the pmle+ty.ormy nmployeea with xgu utheh sole compensation, nmksimin A and rAviginng
willdodue wmkend Ne suucture isnot intended oro@red recalls(Sec.7044,Business eons leted Blue Priii49u;red Inspections
and Pmressinu Cade:The Canuaetor's Licenu Law does not apply w an owner of o}��.(C�.�, Tµ1ir e P
pmpenywhobulldanded thatuch Imprandwho doenoehunted omcelfor through Ms PGIALNt gO 1111fT/days
awnempwyuutildi idedlhaleuchlm n,andw Uartnot inlwork meelfor tar percale.If, R.
^J
however,the building m Improvement Is mid within one year of completion.the owner-
builder .will hue the burden of proving that he did not build m improve for purpose of
1.,
�V—+I�7
❑I,a steno of the property am exclusively cutuning with licensed mnoscntra to F
comwct the pmjm(Sec.7044,Business and Profusions Code:)The Contractors Li.comment }O5 — ANCHOR TS
cute Law does not apply w an owner of progeny who builds or improves theaon.red, SlE�sletlue
who for such projects with a eontam
ewr(s)licensed pursuant to the Omewfs tLYu,
nLaw'
0la202 - PLUMBING
Tem exemptder unSec. ,BkPCrm Ulla reason
Owner Dat DaW - D R MECHANICAL
WORKER'S COMPENSATIONDECLARATION 204 - DE O R FRAME
!lawI hereby atBm under penalty of perjury one of the following decluatlome 205 - UNDERFLq OR INSULATION
ate and will maintain a CenlRcate or Consent to sel6insum for Workers Compere- 301 — ROUGH P. UMBING
prothis hersed77oo or taw Labor Code.for the perrarm.nee of the 302 — TUB & OR SHOWER
❑I have and will maintain Warktes Compensation Interims,at required by Section 303 — ROUGH MECHANICAL
3700 of the labor Code,for the performance of the work for which this permit Is lssud. 304 — ROUGH ELECTRICAL
My Workers Compensation Insurance carrier and Policy number am:
Ca der. v N.n E Poucy'E' 9033 �y 305 - FRAME
CERTIFICATEOFEKEMFf10NPR MWORKERS' 3O6 — HOEDOWNS
COMPENSATION INSURANCE
(This seclian need not becomplered lithe,Permit is foronc hundred dollars(SIM) 307 - INSULATION
mkaq _ 308 - SHEETROCK
Isentry that in the srtiomams or 144 work for which this permit t Issued,I shall nm 309 - EXTERIOR LATH
employmy persue in my meaner an u w Msomasubject to the Workeri Compensation 31O — INTERIOR LATH
Laws of California.Date
Applicant 311 - SCRATCH COAT
NOTICE TO APPLICANT:IL art,making this Ccniro:ale of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must 313 - ROOF NAIL
zO mMwuh comply with such pmvidnmwthis peeress mmbedeemed revoked. 501 — FINAL ELECTRICAL ENERGY
CONSTRUCTIONLENDINGAOENCY 502 - FINAL PLUMBING ENERGY
[r'2 1berchy.M.shat there lea construction lending agency for ince perfowum:of
a > the wuric for which this Permit tissued(Sec.3097.Co.C.) 503 - FINAL MECHANICAL EN i
117 Q Lenders Name 504 - FINAL BUILDING ENE 'Y
D z Lenders Address
U O 1 certify that I haw read Wnpplication and sure that the show Information Is 5 0 5 - F I NAL ELECTR I CAL
> F comm.I agree to comply with all city and county oNimmus and ares laws reading to 5 6 — GAS TEST
OU building conswellon,and hereby authodue repruentatiws or this city to enter upon the
W a1avomen0oned property for inspection purposes. O FIN L PLUMB'NG
(We,)agree to taw,indemnify and keep haemins the City of Cupertino against 8 F I AL
liabilities,judgments,core and expenses which may In any toy acme against Wd City C�li
U 7 in consequence of the granting of this Permit.
�7 APPLICANT UNDE ND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU B L
Re-roofs 514 INAL PUBLIC WORKS
PfumI of Ap licm n or
HAZ D US MATERIALS DISCLOSURE Type Of ROOF
Will she applicant or a urs building occupant store or handle haysrdous material
as dcMcd by the Cupertino Municipal Cade,Chapter 9.13,and the Health ad Safety
Cade.Section 15532(x)7
[D Yes No All roofs shall be inspected prior to any roofing material being installed.
40Will the applicant or future building occupol tau equipment w devices which If a roof is installed without first obtaining an inspection,I agree to remove
hemm us air ntwiunu as meed by tins Bay Aru Air Quality Mmagemcnt all new materials for inspection.
drictl m
❑Yu u
a
1 have mad the haurdous materials requirement under Chapterfi.95 orthe Califor.
niaHullhk SafetyCude.Swilues 25505.15533 md2553/.I understand thatirlhe building
dims not cumnlly ha ¢mart,dl I Il t my responsibility to modify the occupant of tiro
regmr „nen or
w ammohCeNne.reoromp ray. Signature of Applicant Date
sera met res agent are All roof coverings to be Class"B"or better