03070059 CITY OF CUPERTINO °� "�%= *tirxx, s �•�� o:� a�`
BUILDING DIVISION PERMIT CONTRAC C,nR:INFO GMAT IOC
BUILDING ADDRESS: SAMUEL CONSTRUCTION PERMITN0.03070059
R'SNAME: 3427 F''LORAVISTA AVE . PERMIT ISSUE DATE
PHONE: (408) 249-2828 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB ARCH
too
LICENSEDCONTRACTOR'S
under
SDECons or CON
-w pp 1 hereby affirm that 1 am licensed under provisions rf Chapter 9(commencing lob Description
:z, with Section TNXS of Division Sof Ne Businsra and Professions Coda and in,license is
Liters ld ;�"t_, Ly `���'77 'z REMODELING 2 ROOMS (428 & 43�INALE®
Da c.nfnar �emwee ns•+ CONTRACTOR: SAMUEL CONSTRUCTION
ARCHITECT RATION JAN 2 12004
rF
i a 1 understand my plans shall M use public records
saU
o
t; Licensed Pmfcisimal BUILDING pn�
OWNER-BUILDER DECLARATION B ®ILDING
1 a S 1 hereby reaso .(fens lnm 11. exempt from the Conln,Co :Any c Law for Nt, V
OO following maznn.(Section 1 construct,
Business and ve dco.s Code:Any city(it
t m
which rets iris a permit in amslme alter,improve,h Permit t or repair any tatcomm
thatheor itscensed c.mkrrcquite the
sofcant forthe sucCoM1racter wfile asi Law
hapten
ilio commencinwith Srction7Nt,pmvusmnsof the Co usinc 'and PrxssionCbapter9 Sq. Ft. Floor Area Valua[�9850
��� commencing a exempt
Scctiun111Wth Division JotN alleged css andon.Ayvilatdd)ion or
3 Nal io u exempt therofmm and the buts for Na alleged exemption.Any violation of .n �i tt.A� p�
Section 7031.5 by anyapplicantfor apertnil subj¢uthe applicant toacivil penalty of 32d81N�s MbeT00 Occupancy Type
not more Nan five hundred dollars(S!500). P Y YP
0 I,as owner of the propery,or my employers with wages as their sole compensation,
will do the work and Ne amucmre is not intended or.ffcred bottom(Sec.1044,Business
and Pmfcations Code:The Comesaoh License Law docs not apply to an owner of Required Inspections
propemy who builds or impmves Nemon,and who does such work himself or through his 101 — FOUNDATION
own employees.provided that such improvements are not intended or offered for sdc.If. 102 — PIERS
howeveq Ne building er improvement is sold within orc year of camplction,Ne owner
build).er will have Nt,burden of proving Nat be did not build or improve for poorest,of 10 3 — UFER
NO 104 — REBAR
❑I,ru owner of the Sec.70proreny,am exclusivelynd confessions with licensed enntncmrs m
construct La the es poet ot apply
t Oan Business and rtywho Wilds
code:)The Contractor:and 10 S — ANCHOR BOLTS.
who contracts
or such pro etwith arommemrty wcesed pursuant to
Nemrn,ars 106 — SEWER & WATER
who contacts fur such pmjccu with a con.aaor(s)licensed pursuem fo Jw Contractors
License
am exe & az
❑ I am antler Sec. ,B P C for this man 202 — UNDERFLOOR PLUMBING
203 — UNDERFLOOR MECHANICAL
r WORKER'S COMPENSATIONDECLARADam 204 — UNDERFLOOR FRAME
by aRrmunder Penalty of pmjury one of the following declarations: 205 — UNDERFLOOR INSULATION
❑Ihaveand will maintain aCenrecaw(if Consent toxinsure for Workers Cempen. 301 — ROUGH PLUMBING
sato.,az provided for by Section JVW of We Labor Codd.for W.performance of the 3 02 — TUB & OR SHOWER
work for which this permit is issued.
0 1 nave and will maintain Workers Compensation Insurance,as required by Section 3 03 — ROUGH MECHANICAL
37W of Ne fatter Code.for the Performance or me work for which this permit is issued. 304 — ROUGH ELECTRICAL
My Wmim�e,Compensation Insurance carrier and Policy mother am: � ry
cr: .5•Yc� �V\ PolicyN /JO 12SO 305 — FRAME
CERTIFICATE OF EXEMPTI1J)PIl MWORKERS' 306 — HOLDOWNS
COMPENSATION INSURANCE iLief '29111011307 — INSULATION
Cribs action need not be completed it the Permit s for one hundred dollars($INB 308 — SHEETROCK
or less]
1 certify that in the performance of Ne work for which this Permit is issued.I shall nut 3 09 EXTERIOR LATH
employ any person in any manner set as to hccome subject o Nt,W.rkers'Compensation 310 — INTERIOR LATH
of
Laws of California.Date
Applicant 311 — SCRATCH COAT
NOTICE TO APPLICANT:If,afmr making this Cenificam of Exemption,you should 313 — ROOF NAIL
become subject to the Worker's Com pensafion provisions of the labor C.de,you must
]Z fordwi Lh comply with such provisions or this Permit thal I be deemed bNoled. 501 — FINAL ELECTRICAL ENERGY
ZO CONSTRUCTION LENDING AGENCY 502 — FINAL PLUMBING ENERGY
I hereby affirm that there is a consb.Rinm lending agency for the performance of 503 — FINAL MECHANICAL ENERGY
X
But work for which this permit is issued(Sec.3091.Civ.C.)
L p Lenders Name 504 — FINAL BUILDING ENERGY
z Lenders Address 505 — FINAL ELECTRICAL
1 certify that 1 have read this application and show that(ht,above ofomafi.n is 506 — GAS TEST
y chimer.1 agree m comply with all city and county ordinances and state laws relating to
Vbuilding construction.and hereby audimiaa representatives of this city to enter upon the FI=tING
abovcmentioned pmperty for inspection purpoaea
i (Wt,).,me to save,indemnify and keep harmless Ne City of Cupertino against ror it. 0 8 FIAL
y liabilities,judgments.eosu and repined,which may in any way accrue,against said City 5 I
in
Of the
rand ng of
his
J z
APPLICANT CUNDERSTANDSIAND WILL COMPLY WITH ALL NON-POINT Issued by:5 Date
SOURCE REG(�ATIONS.
— Re-roofs 514 NAL PUBLIC WORKS
rlut`c act., Dam
NAZIRDODS MATERIALS DISCL URE Type of Roof
Will Ne applicant or future building.ccupant store or handle harmdous material
az dcfncd by Ne Cupeni no Municipal Code,Chapmr 9.12.and be Health add Safety
it,Section c,,cti. 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
40
Will the eppliwm or future building occupant tax aqui for devices whin If a roof is installed without first obtaining an inspection,I agree to remove
men
emit harardnus air contaminants as dcfncd by the Bay Arca Air Qualify Management
Di,uicf? all new materials for inspection.
O Ycs ,1lINu
I have road Ne ha udom materials requirements under Chapter 6.95ofNeCalifor-
nia 11cp W k Sarmy C. .Sced.ns 255115,255]3 and25534.1 undcrsmnd Naf if Ne,building
docs not curcndy haw a temans,Nat h is my respnnsihility m n.fily Jre rccupm(t f Nc
mquirchichus whichmust beMCI� Ipd�rtT_erinfacc.;raw.rOcc�anty. Signature ofApplicant Date
Ow.er.r a., arrl,gee Dam All roof coverings to be Class "B"or better