03020106 CITY OFCUPERTINO
BUILDING DIVISION PERMIT t4C,0 I'R'ACMATIQN .
Btj1Igjga2ft3DRNS:DE. ANZA BLVD PERMITNO.03020106
owN€33rIC RICHFIELD/ARCO GASPEIaMrr"RA7g 9/2003
MAY 2 2003 L
SANITARY NO, CONTROL NO.
RMLOING
ARCHITECT/ENGINEER; BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�oo LICENSED CONTRACTOR'S DECLARATION
�uF Ihereby.ffrrm Nde
al l am licensed unr provisions of Maptar 9(Commencing Job Description
n� Mch Section 7")of Division 3 of the Business and Profctdom Code,and my licenm is
In full forte sols ` I�g )d _778088 TI--REPLACE TANK TOPEQUIP/PRODUCT &
^1b DatanmG D Con r -
"" r- r VAPOR LINES/DISPENSER/ISLANDS/LEAK MONITOR SYST
3RCHPIECI'SD ATION
1, dcstand my plans Ndlbeumd asps crecnrd. CONTRACTOR: SLUNAKER CONSTRUCTION
D ..
3�g Licensed Professional
3 OWNER-BUILDER DECLARATION
I 1 hereby elBrm that 1 em exempt from the Comremor's License Law for the
OF following reason.(Section 7031.5,Business and Professlnm Cade:Any city or enunly
$ which requires a permit to construct.altar,improve,demolish,or repair Any structure
prior in its issuance.also requires the applicant for Inch permit to Ole signed mmmenl
thatWisliccnmdpurtuanwfintprovisiomofthc Crnlrmroe Liceemlaw(Chnper9 Sq.Ft.Floor Area Valuation
SC$ (commencing with Section 7")of DivisFon 3 of the Bol.and Professions Carlo)or
3.. that be is exempt dwermm and the basis for do Illegal exemptlon.Any violation or
actome Nan nbw A"
Applicndred dollars(i5Wrmit subjects the applicant to A civil porosity of APN Number $�p*®t(.y Type
0 1.u mw.of the property,or my employer with wages a that,rule campewdon,
will do the wok.and the smetuta Isnot intended or offered fonds(See.7044,1hutiness
and Proressiom Code:The Conuamon't Uceme Law arcs not apply in an owner of 8 O O Required Inspections
property who bul lain or harrows thereon,and who der such work himself or through Ms
own emptoyea,provided thataveh improvements are not lnended croaered(mule.if, 101 — FOUNDATION
however,Ne building at improvement is mid within one you of completion,the owner.
builder will have the burden or Proving that be did not Wild or Improve for purpose of 102 — PIERS
ask.). 103 - UFER
0 1.as owner of the property,am exclusively Contlmting with licensed contractor,to
construct the project(Sec.7044.Business and Protrusions Cade:)The Contractor's Lb 104 — REBAR
muse law duct not apply in In owner of property who Wilds or improv thereon,and, lO5 — ANCHOR BOLTS
who contracts for such projects with a comrtetor(d Ilcamed pursuant to tie ContracmY.
License taw, 106 - SEWER & WATER
O lamexemplundu See .BkPCfmthismamn
202 - UNDERFLOOR PLUMBING
Date-
wnu WORKERS COMPENSATION DECLARATION 203 - UNDERFLOOR MECHANICAL
I hereby Affirm under penally,of Perjury am or the following declarations: 204 — UNDERFLOOR FRAME
(3 l haw and will maintain a Certificate ofCrnmntm self-imum for workeraConran. 205 — UNDERFLOOR INSULATION
nation,As provided for by Section 3700 of the labor Code,for the performance of the 3 01 - ROUGH PLUMBING
work err which this permit I.issued. 302 - TUB & OR SHOWER
0 1 haw and will maintain Worker's Compensation Insurance,As required by Section
370(1 of the Labor Code,for the performantt of the wok for which lois Permit is issued. 303 — ROUGH MECHANICAL
My Workce.Crmrematien mmmnm carrier And Policy member.: 304 - ROUGH ELECTRICAL
carrier: 5T+TE FUND P If N : 22893-20c,3i% CERTIFICATE OF P.%EMP110N FR MWORKERS' 305 — FRAME
COMPENSATIONI ANCE 306 - HOLDOWNS
(This section need not be Completed if the Permit is for one handed dollars(S 1011) 307 - INSULATION
mWa) 308 - SHEETROCK
1 cenl(y that In theperformenrc of the wok for which Nis PermitIn iuwl,I shall nm
employ Any person in any manner ansa in become subject to the Workers CompensNon 309 — EXTERIOR LATH
ApplicanCelifornla.tie¢ 310 - INTERIOR LATH
NOTICE TO APPLICANT:PL after making this cenl0cale or Exemption,you should 311 - SCRATCH COAT
become subject to the Worker'.Compensation provisions of the Labor Carlo.you must
,JO Forthwith comply with such provisions or this Permit hall be deemed revoked. 313 — ROOF NAIL
CONSTRUCTION LENDING AGENCY 501 - FINAL ELECTRICAL ENERGY
[•+E2 IAInk,snore that them is A moumctlnn loning.immy far the performance of
tX> tho work for which this Permit tsissued(Sm.3097.Ch,C.) 502 _ FINAL PLUMBING ENERGY
u3p
Leader'aNune 503 - FINAL MECHANICAL ENERGY
6, Lenin's Address
�Z 504 - FINAL BUILDING ENERGY
UO Icertifythat lhaw Me!this Application adme,M,hcAM.infmmntion4 505 - FINAL ELECTRICAL
coral.I Agree to comply with all city and county ordinances and rete JIM helatint to
0U building construction.and hereby authurine cepchemadw,of this city to toter upon the 4GA2ESTfehmcmentionedpropeny for imPection Purpom,.(We)agree Io saw.indemnify and keep humleu the Clly of Cupertino agdn,t O 7 IA liabilities,judgments,costs and expenses which may In any wry ammo against add City 55 AC
U in consequence of the granting of this Permit.
APPLI�pNT/I1NSTA�NNAND N(JQL COMPLY WITH ALL NON-POINT Issued by:5 Date
SOU R /lU INS.
N YJAI4°3 Re-roofsPLANNING
Itum car Ire HAZARDOUS MATERIALS DISCLOSURE Data Type of Rooj4 - INAL PUBLIC WORKS
Will the applicant w future building mcup.m nmre or handle hamdom mistrial
as dented by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safely
I
e.Section 25532(x)7 All roofs shall be inspected prior to any roofing material being installed.
0Yes MM.
Will the aMlicarl or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
havardous air contaminants u darned by the Bay AM Air Qudlly Management all new materials for inspection.
0 Yc. l�1 have mad the hazamrms material.requirements unlerChopwr 6.95 or the Cdifor.
Health a Safety Code,Salons 25515,]5533 and 25534.I understand am if the Wilding not cement net.Net it is my ndbllily m entry the remprn ale m t merpdnrroivn neeAnesanrOcc may. Signature of Applicant Date
w t,.w y 2 y�09
o nr.ntnn d.gent Data All roof coverings to be Class "B"or better