03080030 CITY OF CUPEW11NO
` J—N
UILDING DIVISION PERMIT CONTRACTOR INFORMATION „
NGADDRESS: MERCER CUSTOM CONSTRUCTIONPERMITN003080030
nOn OUT ATRE QT
SNA 1 619 HAWTHORNE AVEf (408) 374-8782 SANITARY 0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
!OEQBLDGTEL ; PLUOMB ME�CH
Ap LICENSED CONTRACTOR'S DECLARATION .r•
w F I hemby affirm that 1 am Beemed under provisions or Chapter 9(commencing Job Descriptio
li t� with Section7M))of Division 3 of he Business and Professions Code.and my license is
' e in full force and effect. it L UY
iq? License Class Lic.p ADD 466 SQ. FT.
�Fp Date Contractor
• 'J` ARCHDECI'S DECLARATION
2 n I understand my plans shall W used az public recoNs
] UVJ Ye
o G Liccnud Professional
I OWNER-BUILDER DECLARATION
ta y I hereby affirm tot I am exempt from the Contractor's License law for the
m� following mason.(Section 7031.5.Business and Pmfeesions Code:Any city or county
5 which requires a permit to comoruct,alter,improve,demolish.sur repair any svuaure
prior m its issuance,also requires the applicant for such permit to til a signed statement
zE< that he is licensed pursuant to the previsions of the Contractors Liecmse Law(Chapter 9 Sq.Ft. Floor Area Valuation
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or
Nat he is exempt therefrom and the basis for the alleged exemption.Any violaion of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of ane APN Number Occupancy Type
notmnt<thann.ehundreddollars(SSW). - P Y YP
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the wMic.and Oeswcmre is nut intended or offered for sale(Sec.7044.Business 101 — FOUNDA
and Pmfcssions Code:The Contractor's License Law dues not apply to an owner ofeT d Inspections
property who builds or improves demon,and who decs such work himrelfor through his 102 - PIERS
Own employees,provided Nat such improvements are not imended or offered for sale.If. lO3 — UFER
however,the building or improvement is sold within an year of completion,the owner
buildar will have the burden of proving Out he did not Wild or improve fur puou of 10 4 - REBAR
sale'. ry105 - ANCHOR BOLTS
1.as owner of c, progeny,am exclusively contracting with licensed contactors m
conswcuhe project(sec.'7BW,Business and Professions Code:)The Contractor's LF 106 — SEWER & WATER
cense law/nes not apply to an owner of progeny who Wilds or improv thereon.and 202 — UNDERFLOOR PLUMBING
who contracts for such projects with a contractors)licensed pursuant to the Contfactore
Licenmexe 203 — UNDERFLOOR MECHANICAL
❑ lam exempt under Sec. .B&PCfor this rcazon
�F t 204 - UNDERFLOOR FRAME
wa KE 'S COMPENSATION DECLA ATI.N 2 205 — UNDERFLOOR INSULATION
I h,.by alfimtt rPenalty of perjury rete of following decimations: 301 - ROUGH PLUMBING
I ban and will maintain a Cenificam ofconum to self-insure for Workers Compcn- 302 — TUB & OR SHOWER
cation,as provided for by Section 3700 of the labor Code,for the performance of the 303 — ROUGH MECHANICAL
work for which Nis permit is issued.
❑ I have and will maintain Worker's Compensation Inuinoec.az required by Schon 3 04 - ROUGH ELECTRICAL
37W of the lobar COO,for the pof.mun<e of Ne work for which this permit is issued. 305 — FRAME
My Workers Compensation Insurance carrier and Policy number am: 306 — HOEDOWNS
Corea: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 — S+HE•ETROCiK
Icss.)(This such.aced""t be completed iflbe permit isfor one hundred dollars(SIM) 309 — EXTERIOR LATH
or
I cenlry Nat in the performance of We work for which this permit is issued,1 shall not 310 — INTERIOR LATH
employ any person in any manner uaz to become subject in the Worsen Compensation 311 — SCRATCH COAT
Laws of California.DateApplicant 313 — ROOF NAIL
NOTICE TO APPLICANT:If.at ter making this Ccrificatc of Exemption,you shou lJ 501 — FINAL ELECTRICAL ENERGY
become subject m Ne Workers Compensation provisions of the Labor Code,you must
� zz forthwith cmn,dywith Such frown oas.1Oisp rmitShall bed<ernedmvoked. 502 — FINAL PLUMBING ENERGY
'Z ^ CONSTRUCTIONLENDING AGENCY 503 — FINAL MECHANICAL ENERGY
[-+ � I hereby affirm Natthereisa mmonecloor lending agency for the strurmance of 504 — FINAL BUILDING ENERGY
f$ 5: hi
the work for wch this permit is issued(Sec.3097.Co,CJ
w Q
Leader'sName 505 — FINAL ELECTRICAL
z UndersAddms 506 — GAS TEST
C.) Q I cenify that I have read this application and sum that Ne above information is
ry P colica.I agree to comply with all city and county ordinances and sum laws relating to 507 — FINAL PLUMBING
pU building construction.and hereby authorimmiresenutivufthiscitytoenteruponthe FIN MEC CAL
a hove Mentioned property for inspection purposes.
y
(We)agree m sale,indemnify and keep harmless site City of Cupertino against 0 9 FIN
h liabilitieajvdgments,costs and expenses which may in anyway scenic agaimtsted City 5 NG /
C.) Z in coneequencc of the timing of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:5 C WORKS Date
SOURCF�EGULATIO
k.kt7 , . 8/Wo Re-roofs
s' nature of Applican Con nor Date
H Z DOES MATERIALS DISCLOSURE Type of Roof
Will that applican ser future W ilding occupant Ston,or handle havarduus material
it riit by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
s«don 2153 CTI' All roofs shall be inspected prior to any roofing material being installed.
Y
cs �No
Will the applicant or future Wilding«c„pant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
7nia
hazardous air contaminants az defined by the Bay Area Air Quality Management all new materials for inspection.
❑Ycs [flu
I have mad Ne lorand az materials requirements under Chapter 6.95 ofNe Califor-
ealth h SafetyCode,Sectio.25505.25533 and 25534.1 nderstand Nat itthe building
not currently haw a tenant.Nat it is my ma,misibiliry m mdly the Occupant of the
imornmh Uatmet prior to issuance ofaccrircamo"9�rycy. Signature of Applicant Date
AX/7)n 0
ow r anthorozdagent D„< All roof coverings to be Class "B” or better