03050072 CITY OF CUPERTINO
BUILDING DIVISION PERMIT rC,U,..NTItAC''PUR I1�FF'U1ATN:.,;
BUILDING ADDRESS: L AND D CONSTRUCTION PERMIT No.03050072
21101 COLUMBITS, A17
R'S NAME: 1555 YOSEMITE AVE . #17 PMi1fff 697'16/2003
It ILING & TONY
PHONE: (415) 822-8383 SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG EIELT PLUMB MECH
o I� I�
YO Zp LICENSED CONTRACTOR'S DECLARATION Job Description
u I Wmby afnrm that I sus u licensed under pmvisicof Chaplu 9(commencing
gwith Section 7M)of Division 3 of dm Buomar and PmfeWuns Code,and my license Is
Lcenm lasde ect REVISION-IN HOUSE USE ONLY
LV Llcenm Clue Lm.
tt-- Dem conwcmr NO NEW PERMIT ISSUED, ORIG. #02120090
p Q ARCHITECTS DECLARATION
1 undersand my plans"I be used u public mcnrN
3 i a8 Liccnsod Profesaianai
u OWNER-BUILDER f DECe ConuoON
I i I hereby ass ml I am attempt from the ConaacmM1 License Lew for the
p o fallowing aurin.(Sadao]1131.5,Buincss sotl Profcssiuns Cole:Any city or aunty
$ which acquires a permit to eonsWct.alar.Improve,demaliah.m repair soy suuctum
Poor m its issuance,also requires the appliesnt forsoch permit to file a signed stammcat
p C
quat be is licensed pursom,to the provisions of dre Cormactues Licerem Law lChaqncr 9 Sq.Ft.Floor Area Valuation
of 5 (commencing with Section TOW)of Division 3 of the Business and Professions Code)or
that M Is exempt therefrom Brad the buts for the Wlaged exemption.My violation of $1000
nodi mom 131.han five h�drtd dollars r a 0).it subjau the applicant to a rnll Penalty of APN Number Occupancy Type
01,u owner of use property,or my employees who wages u their tole compensation, 36205032 ' 00
will de the work,and the stsumum is not inmaded OroRemd far sale(Sao.IDM.Budrru Required Inspections
and Prone olou Code:The Conaumr's Liaise law does not apply m an ower of 10 3 — UFER q P
property who Wildsorimprove thereon.and whodoessuch workhimalfortiuou{6 his
awnemployea,provided that such Improvements am not mmndetlaraRemdfareala.u, 304 - ROUGH ELECTRICAL
however,the Wilding or improvement it sold within arc year of completion,the Owur-
bullder ,will have Ne burden of proving that he did am build or improve for purpose of 505 - FINAL ELECTRI CAL
sate.).
1.u owner of the property,.Business euand eonasotlnal CIN:)Theed eonauma m
co se La the project(Sec.he an.wnrorand ProfessionalWild,
Cade:)Theve,do
er. red ,g�
U.
auc law doss not such
e ts owner of property who sed p m improve Norton,and
who contracts for each projects with a anuumr0)licensed punwnt ro the Contractors C
4me.law. \
❑tem exempt a Sec. .B A P C/for
(�.ds mason
f Date ,9 r
C NSATIO EC ATION
I hereby an.under Penalty of per anc If following decimalom:
I have and will maintain•CertlMue ofCummnt to wlf-ivum farWaresesCmnpen-
sauon,u provided fm by Smdon 37W of the labor Code,for the performance of the
work for which Nis permit is issued.
❑1 Itave and will maintain Workers Compensation Insurance,u required by Section
3700 of the Labor Code,for the performance often work far which this permit Is Issued.
My Worker's ComPenuaon Insurance carder and Policy number sae:
Cartier. - Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis section ucd not be completed If the permit Is fortune hundred dollen($I00)
or mu)
1 certify Nu In th rfmmance of the work Ire which this permit m iuncd.I shall nen
employmyPersons mennfrmy.tpb arge sublatto use Warkeri Canpenution
Tawe ar Califami _ F-Lb
NOTI
NOT
P ser sting this C IDCta of E Latour o d you should
become Subject comp m the Workers Compensation Permit
sou or sax Leeds Code,you aur
,`� faMwith eomP1Y with such provisions or Nis permit shill M decreed reeked.
ZO CONSTRUCTION LENDING AGENCY
[-. 1 hereby affirm duet them is a construction lending agemy far the rs rfmmana of
6i the work for which Na Permit is Wood(Sec.3097,Civ.C.)
0 Lendersciv
Nunc
;;)Z Lender's Addrus
V Q 1 certify dust 1 have mad this applialloto and sum Nu the ebave information is
{gr ` correct.I agree to comply with all city and comity ardlnNaa and state laws relating m
p U building conmuction,and hereby authodea representatives of this city to enter upon the
4LI above-menumted Property fm Inspection PorWaa
gy (Wc)agree to save.Indemnify and kap hermleu the City of Cupertino against
fpr liebiliva.judgmenu,emu and expenses which may in any wayacme again said City
U in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREIONS. %
Re-roofs
Sign are ser icauC mom— D
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant on future building accupuusom or handle husrdous material
defined by the Cupertino Municipal Cade.Chapter 9.13,and the Health and Safety
Secaon ss532 a) ,J All roofs shall be inspected prior to any roofing material being installed.
❑Yes *future
Will the applicant m f'ut`ure building=upon,use equipment or devises which If a roof is installed without first obtaining an inspection,I agree to remove
emlt hesallous ait onWninuta as defined by the Bay Area Air Quality Management all new materials for inspection.
Dimicff
0y ANu
1 havemW thehaurdoesmateriels mquimmenu under Chapter 6.95 of the Califon
nia Halk SafmyCodc.Secuau 25$115,23533 uW 25531.1 undermost dol ifua building
does not currently how a tensor,that It is my outponsaility m near ecc sat of the
immenawnymmmxmatpdarmwagna%fecaIII ofoec Signature of Applicant Date
Uil G l
Owner m athmrriyed egg h 0/16/ All roof coverings to be Class "B" or better