03060098 CITY OF CUPERTINOg �ry ',I `* Lay"''' -I
BUILDING DIVISION PERMITQ3'�°LV6,g1 � Yl `,syglu� A
BUILDING ADDRESS: LEI ENNIS PERMIT NO 03060098
OWNER'S NAME: PERhDT LS5178DA7$ ,2/2 0 0 3
SANITARY NO. / 1 CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
[� 1�
�00 LICENSED CONTRACIOR'S DECLARATION Job Description
I hereby affirm Nat 1 me licensed under provisions of Chapter 9(commencing
with Section 70(0).f Division 3 of We Bud..and Professions Code.and my license Is
infall force no enema
IJcense Cleo Lk.« REVISION--IN HOUSE USE ONLY
D'te Contractor ARCHI7ECTSDECLARATION NO NEW PERMIT ISSUED, ORIG. #03020077
I unmounted my pins shall bo used as public accords
5 u Licensed Prefessiond
Oat lam exempt
From
DECLARATION
i 1 boreso .Rion that 1 1. exempt tram Ne Cantns Co Licence law for the (�
O O following mama. crit 7/813,B.she.land pmfee moll Code:Any city or countytum V
hbh !in issaapermit reeaes the
aapse.nt forse,h pencils rie a sigsay animal
1.a paarmiuiensedpalsum the thovisio applicant mchperte",Len.Law stawmenl
�< that he en licensed pwmenuothe of Division
aline Comsiness License Law(Chapwr9 Sq.Ft. Floor Area Va IOn
that he 1.ang aper Semian sand We hubof 3.f al egad Business and on,Any
ldon of
� Nu he w eatmpt therefrom and Ih bub for the alleged taemption.Any violNon a( 0
Section 7031.5 by any applicant for a peank mbjecu We applicant to a civil penalty of APN Number Occupancy Type
not mart Was,five handled dollua($SWA 32617028 00
❑Las"Am cribs property,a my employe"with"gnu their sok compensation,
willdo We work,and Neswctore h out intended oroRemd farads(Sec.7044,Business Re I dins actions
and Pmfewans Cade:The Conuxim's License taw does not apply e an Maur of 101 - FOUNDAT��� p
property who builds car im provea Neamn.a nd who dans meinwart himsel f car through hos
own employers,provided Nat such lmprmementare natimenda croRered for sale.l6 102 — PIERS
however,the building or improvement is sold within am Sear of compledas.the owner.
builder will lure the burden of proving Nat he did not build An improve for purpose of 103 - UFER
eale'). 104 - REBAR
0 1,As owner of des,property.Are exclusively centricting with fiecused camuncomas to 105 - ANCHOR BOLTS
construct Ne project(Sec.IDN,Business and Professions Code:)The Contractor's Lb
cause Law dons act apply w an owner of property who builds or Improves,Woman,and, 106 — SEWER & WATER
whocontracuforsuchprojectsvn ecam=M*)licensedpuneantw WeCantr es '
Liey5nutaeeLAW. 202 - UNDERFLOOR PLUMBING
ISrm exempt under Sec ,B&Pcfm areae 203 - UNDERFLOOR MECHANICAL
W OMP oNDEcu ATION ? 204 - UNDERFLOOR FRAME
I hemby,affirm Wader pews ury one of following dealanuans: 205 - UNDERFLOOR INSULATION
ve and will maintain a CenlEnte of Consent to self-Inevn for Worker's Compon• 301 — ROUGH PLUMBING
. ...An provldW for by Sordoni 3M of We labor Cade.for Ne perfume.of ft302 - TUB & OR SHOWER
warkforwhichthispermitisisued. 303 - ROUGH MECHANICAL
3700 of We'n'iaWrCoa"anteaaKorma�e neck"i�hiUrequired emitish`�w 304 - ROUGH ELECTRICAL
My Workers Compensation lmmrnme carrier and Policy ro mber am: 305 — FRAME
Cartier. PolicyNo.; 306 - HOLDOWNS
CERTIFICATE OF EXFMYnON FROM WORKERS'
COMPENSATION INSURANCE 307 - INSULATION
tTTb section reed not wcompleted if We permit xfmonchundmA dallan(SIOD) 308 - SHEETROCK
mtele') 309 - EXTERIOR LATH
1 canary that in de perfomtance of We work for which this permit is Issued.I shall not 3 10 — INTERIOR LATH
employ any perms in my manner m u m become subject to We Workers'Compensation
Laws of California.Date 311 - SCRATCH COAT
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should 313 - ROOF NAIL
became subject he We Workan s Campensadon provisions of the Labor Code,you must
>Z foMwithcomply what such Provision orthis permit annxdeemednw.ked. 501 - FINAL ELECTRICAL ENERGY
z CONSfRULTIONLENDING AGENCY 502 - FINAL PLUMBING ENERGY
I homey M.that Wens lea..=do.lending agency far the perfoo mu.of 503 - FINAL MECHANICAL ENERGY
z> work for 504 - FINAL BUILDING ENERGY
37 Q Lenders Name
=Z ander'aAddrem 505 - FINAL ELECTRICAL
J o 1 certify On,I have read Nis application and cum than de above information b 506 - GAS TEST
L correct.I agree la comply with all city and county ordinances and stew laws minting to
Wilding construction,and hereby mNodm representatives of this city to cnes upm We FINAL PLUMBI G
above-mentioned property for impc es purposes. 11
S"W (We)agree m ane,indemni and keep harmless the City of Cupertino against 0 8 F I L 1 �
y y 11.bllmea.judgmenu,cwu ande. oma which may In my way accrue Against old City A /
J Z in consequence of the granting Nu
APPLICANT UNDERS'fA s AN W L LY WITH A N N P01 Issued by:5 NG Date
S URCERECULATI
Re-roofs
Ignuure of APPhe.nVConuector caw
xAZARDous A ALS DISCLOSURE Type of Roof
Willtheapplieantor fmuralist " goceupamstomer luuWwhusWosmatcriat
u dented by We Cupertino Munict Code.Chapter 9.11,and the Health and Safety
can,Section 25531(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑You 0
Will the ap/t--dmm
but ing occupant use equipment m devices which If a roof is installed without first obtaining an inspection,I agree to remove
havamaw AirLned by the Bay Area Air Quality Management all new materials for inspection.
nuict7
❑Yes
I h
ave reW ateri mryiremenuunderChapter693ofdteCaii(aryria Health&Sefmyd 2553e.Iundcr.mnaNuifNe building
docs tut currently lbilitymnotifytannceup tomqui men whhmof.Cenineateofoccuu Signature of Applicant Date
17,
Owner or mthovetl agent ,te AI I roof coverings to be Class"B"or better