03050037D�2
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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
CONTRACTO][2 INFORMATIC,,.
BUILDING ADDRESS:
PERMIT '9
03050037
OWNER'S NAME:
PERMIT ISSUE DATE
0811.8/2003
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in fan force and effect.
TENANT IMPROVEMENT
License Class Lic. M
Date Contractor
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior m its issuance, also requires the applicant for such permit to rile a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
1621090.00
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
3
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
1, as owner of the property, or my employees with wages as their sole compensation,
lui —
d. Inspections
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law docs not apply to an owner of
102 -
PIERS
property who builds or improves thereon, and who docs such work himselfor through his
own employees, provided that such improvements are not intended or offered for sale. If,
103 —
UFER
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
104 -
REBAR
sale')'
105 -
ANCHOR BOLTS
W. as owner of the property, am exclusively contracting with licensed contractors to
10 6
SEWER & WATER
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
-
cense Law docs not apply to an owner of property who builds or improves thereon, and
202 -
UNDERFLOOR PLUMBING
who contracts for such projects with a c or(s) licensed pursuant to the Contractor's
License Law. — -
203 -
UNDERFLOOR MECHANICAL
❑ 1 am exempt undeySeE: , B & P C foe this. reason
204 -
UNDERFLOOR FRAME
w r ,/ ale(�4
205 -
UNDERFLOOR INSULATION
WORKE ATION
I --nm tm under penalty of perjury one of the following declarations:
3 01 -
ROUGH PLUMBING
302 -
TUB & OR SHOWER
❑ [have and will maintain aCertificate ofConsent t°self-insurufor Worker'sCompen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
303 -
ROUGH MECHANICAL
work for which this permit is issued.
304
- ROUGH ELECTRICAL
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit ;s issued.
3 05
— FRAME
My Worker's Compensation Insurance carrier and Policy number are:
306
— HOLDOWNS
Carrier: Policy No.:
307
- INSULATION
CERTIFICATE OFEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
308
- SHEETROCK
(This section need not becompletcl ifthe permit is for one hundred dollars ($100)
309
- EXTERIOR LATH
or less,)
310
- INTERIOR LATH
1 certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so as to become subject to the Workcrs Compcnsation
311
- SCRATCH COAT
Laws of California. Date
Applicant
313
501
- ROOF NAIL
- F I NAL ELECTRICAL ENERGY
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
502
- FINAL PLUMBING ENERGY
503
- FINAL MECHANICAL ENERGY
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
504
- F I NAL BUILDING ENERGY
' the work for which this permit is issued (Sec, 3097, Civ. C.)
Lender's Name
505
- FINAL ELECTRICAL
Lender's Address
506
- GAS TEST
j 1 certify that I have read this application and state that the above information is
507
- FINAL PLUMBING
correct. I agree to comply with all city and county ordinances and stale laws relating to
building construction, and hereby aalhori7e representatives of this city to enter upon the
CAL
above-mcnuoned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
0 9
liabilities, judgments, costs and expem8es ich may in any way accrue against said City
5
NGin
consequence oftheofAPPLICANT UNDERSTANDS AND IL-L�MPLY WITH ALL NON -POINT
Issued by: 5C
ON4�,CHAN
WORKS Date
O CE
' Re -roofs
Type of Roof
i f'
Signa(urcofApplicaV.Ge ractor ! MDat
S MATERIALS DISCLOSURE
!� �,._—HAZARDO
C—A'tfrthe applicant or future building occupant store or handle havardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section 25532(a)?
All roofs shall be
inspected prior to any roofing material being installed.
❑ Yes �No
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
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management
all new materials for inspection.
District?
[3 Yes No
I have read the hazardo s mater Is regairemcros under Chapter 6.95 of the Califor-
nia Health & Safely Code; Sections 25505 25533 and 25534.1 understand that if the building
docs not cumntly'fiave a tenan4 that its y onsibility to notify the occupant of the
requirements which must be met prior a`CcniGcatc of Occupanc. y
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner `authorized ggefii Date