03040128 CITY OF CUPERTINO m.A"r M's�' +r s�'fx' kv
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION ��.:
BUILDING ADDRESS: PERMIT NO.
03040128
gm�A.� ESTATES 5R PERMIT ISSUE DATE
06/06/2003
t0SANITARY NO. CONTROL NO.
ARCHIEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O D D O
BOO LICENSED CONTRACTOR'S DECLARATION Job Description
WU C 1 hereby affirm Nat 1 am licensed under provisions M Chapter 9(commencing
with ith Section 7")of Division 3 of the Businuaand Profcuiaos Codc.and my license is
in full fora and effect.
9'p_ License Class sec.• ADD 715 S Q. FT.
=ro Dau Comnxmr ��m NA®
p ARCHITECT'S DECLARATION rims
B cf 1 uA&,..d my p1.M.h.11 W used as public ceconds
s u0 Licensed Pmfcssional
FEB 1 3 2004
g OWNER-BUILDER DECLARATION
iP 1 hereby.(firm Nal I amL exempt from tW Contractor's e:Any C Law for the lwt��
00 which r.lkwrag...A.(Section lfn L5,Business and are d.rona Code:Any city Of county BAOV�
LDINm
Ami which requiresapmmitc.also e construeplugnt for Suh Perlia ore repair
gned ,nmmurt u
°�'^ pat In,s fieco pursuntto dW the applicant for such Permit to ficusse Ln (Cluddr9
-�< Thank is liccvcd pursuant to provision of the Connector's license law(ChapUm9 statement
Sq.Ft. Floor Area �{) U tion
'Hn (commencing with Section TBW)of Division 3 of the Business and Professions Cock)or 80J
i $ that k u eampt tkrtfmm and the basis for Ik alleged esempdon.Any violation or
Section 7031.5 by Ary applicant fora permit.ubjecv the applicm 1.s civil penalty of
not more than five hundred dollar.($5003. 3 64111.*eb 0 Occupancy Type
❑l.uo erofthepmpcny,ormycmploycuwithwagasstheirmlecompcnatlon,
will do the wort,and the structure is norintcnded..fired foraalc(Ste.7(Ha.Business 101 - FDUNDA'REQD�ed Inspections
and Pmfessioa Calc:The Contractee License law row does t apply an owner of
property who build,in impmu thereon.and who doessuch work himaclfortluough hit 102 - PIERS
own employees,pmvided that such improvements are not intended aro@rod for ale.If.
however.fie building or improvement is sold within one year of completion,the owner. 103 - UFER
builder will have the burden of proving that k aid not baud or improve for purpose of 104 - RE BAR
ale.).
a owner of the property,am exclusively contracting wish licensed contractors to 105 -
ANCHOR BOLTS
construct Ne project(Sec.701a.Business and Pro(esdom Code:)The Contractor's Li. 106 - SEWER & WATER
cave law docs not apply to an owner of property who Wilds or improves thcmon,and 202 - UNDERFLOOR PLUMBING
who eo traces for such pointers with a eonf actor(a)licensed pursuant o the Contractor's
Lictnselaw. 203 - UNDERFLOOR MECHANICAL
❑1 exem0 .B&P C foT Nu'A
qi Date 03 204 - UNDERFLOOR FRAME
�• WORK 'S COMPENSATION DECLARATION 205 - UNDERFLOOR INSULATION
I hereby affirm under Penalty of perjury one of the following declarations: 3 01 - ROUGH PLUMBING
_J Ihave ad will maintain A Cmdoeate of Consent to ul(4naum for Workre,Compcu 302 - TUB & OR SHOWER
Orion,As provided your by Section 37M of the labor Codc,for the performance of the 303 - ROUGH MECHANICAL
work for which this permit is issued.
O 1 have and will maintain Worker's Compensation Inuuna,as requiced by Section 304 - ROUGH ELECTRICAL
37W ofthe labor Code,for Ne pcdarmanec or the wort for which this permit is issued. 305 - FRAME
My Wmk,ea Cnmpcnsution Immena carrier and Policy numkrau: 306 - HOLDOWNS
Carrie. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' 307 - INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
or las.)(thin season need Act tar complead if permit is for one hundred donars(s1W) 309 - EXTERIOR LATH
1 eenify Net in the pe,fame.m.or the work for which this permit is issued,I shall not 310 - INTERIOR LATH
employ any person in any.011e,sn sswbccomc.ubject to tW Workers Compcnssion 311 - SCRATCH COAT
laws of California.Dau
Applicant 313 - ROOF NAIL
NOTICE TO APPLICANT'.If.after making this Ccuifcate of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
Income subject to the Worker's Compensation previsions of the Labor Code,you must
.J'Z forthwith comply with such provisions or this Permit shall k deemcd evoked. 502 - FINAL PLUMBING ENERGY
ZD
Hi'te-. CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERG
aIWmh a(fmn that Unum is a construction lending ac for the formance of
>
the wurkfor which this pemtitisissued IS..3077.CivC) Per 504 - FINAL BUILDING ENERGY----
ap Urrult'aName 505 - FINAL ELECTRICAL '
>z LAaer.Aadrts 506 - GAS TEST
U 0 1 certify Net I have rad sit,application and suis that the.1bve information is
Correct.I agree to comply with all city and county ordinances and suis laws minting of 507 - FINAL PLUMBING
O
U building construction.And hereby authorize opersentilloci Of thiS City to enter upon she 5 - FINAtm�ORXS
L
I17 abwe-mentioned pmpenY for inspection purposes
(We)aster to Ove,orfindcounifyct and trcp harmless the City of Cupertino asairut 5 9 F I N is
lap liabilities,judgments.casts and capcnaa which may in any way neem.against kind City 51 !/i�
C)z APPLICACNTeof UND RSTANDSthis
AND WILL COMPLY WITH ALL NON-POINT Issued b}5 Date
4
s0 RCE#EifiXontor
Otl
�' _ � Re-roofs
gnaturt mf Appl HAZARDOUS MATERIALS DISCLOSURE Dau Type of Roof
Will the applicant Or future building Occupant nmc in handle huardous material
As def ncd by the Cupertino Municipal Code.Chapter 9.12,and the Halth and Safety
de.Section 255324)? All roofs shall be inspected prior to any roofing material being installed.
❑Ya
Will the applicant or future building oecupam Ase equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit haoinh us air conurnmAts As defined by the Bay Area Air Quality Management all new materials for inspection.
District?
0Y., J
Ihmmce Ne Wer msmamrialstequiumenuunder Chapwr6.95of Nc Califon
iliaHOINhSNctyCatic.Sccoom 23NI5,25533 en025534.1 undcrsund Nmif Nc Wilding
dos not currently have a loom Net it is my remoaibilay w Amory the occupant of the
my nus wiaAaamraccrditau,foe pJ�D3 Signature of Applicant Date
Amer or ti adred agent �6 Date All roof coverings to be Class"B"or better
CITY OF CUPERTINO m.A"r M's�' +r s�'fx' kv
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION ��.:
BUILDING ADDRESS: PERMIT NO.
03040128
gm�A.� ESTATES 5R PERMIT ISSUE DATE
06/06/2003
t0SANITARY NO. CONTROL NO.
ARCHIEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O D D O
BOO LICENSED CONTRACTOR'S DECLARATION Job Description
WU C 1 hereby affirm Nat 1 am licensed under provisions M Chapter 9(commencing
with ith Section 7")of Division 3 of the Businuaand Profcuiaos Codc.and my license is
in full fora and effect.
9'p_ License Class sec.• ADD 715 S Q. FT.
=ro Dau Comnxmr ��m NA®
p ARCHITECT'S DECLARATION rims
B cf 1 uA&,..d my p1.M.h.11 W used as public ceconds
s u0 Licensed Pmfcssional
FEB 1 3 2004
g OWNER-BUILDER DECLARATION
iP 1 hereby.(firm Nal I amL exempt from tW Contractor's e:Any C Law for the lwt��
00 which r.lkwrag...A.(Section lfn L5,Business and are d.rona Code:Any city Of county BAOV�
LDINm
Ami which requiresapmmitc.also e construeplugnt for Suh Perlia ore repair
gned ,nmmurt u
°�'^ pat In,s fieco pursuntto dW the applicant for such Permit to ficusse Ln (Cluddr9
-�< Thank is liccvcd pursuant to provision of the Connector's license law(ChapUm9 statement
Sq.Ft. Floor Area �{) U tion
'Hn (commencing with Section TBW)of Division 3 of the Business and Professions Cock)or 80J
i $ that k u eampt tkrtfmm and the basis for Ik alleged esempdon.Any violation or
Section 7031.5 by Ary applicant fora permit.ubjecv the applicm 1.s civil penalty of
not more than five hundred dollar.($5003. 3 64111.*eb 0 Occupancy Type
❑l.uo erofthepmpcny,ormycmploycuwithwagasstheirmlecompcnatlon,
will do the wort,and the structure is norintcnded..fired foraalc(Ste.7(Ha.Business 101 - FDUNDA'REQD�ed Inspections
and Pmfessioa Calc:The Contractee License law row does t apply an owner of
property who build,in impmu thereon.and who doessuch work himaclfortluough hit 102 - PIERS
own employees,pmvided that such improvements are not intended aro@rod for ale.If.
however.fie building or improvement is sold within one year of completion,the owner. 103 - UFER
builder will have the burden of proving that k aid not baud or improve for purpose of 104 - RE BAR
ale.).
a owner of the property,am exclusively contracting wish licensed contractors to 105 -
ANCHOR BOLTS
construct Ne project(Sec.701a.Business and Pro(esdom Code:)The Contractor's Li. 106 - SEWER & WATER
cave law docs not apply to an owner of property who Wilds or improves thcmon,and 202 - UNDERFLOOR PLUMBING
who eo traces for such pointers with a eonf actor(a)licensed pursuant o the Contractor's
Lictnselaw. 203 - UNDERFLOOR MECHANICAL
❑1 exem0 .B&P C foT Nu'A
qi Date 03 204 - UNDERFLOOR FRAME
�• WORK 'S COMPENSATION DECLARATION 205 - UNDERFLOOR INSULATION
I hereby affirm under Penalty of perjury one of the following declarations: 3 01 - ROUGH PLUMBING
_J Ihave ad will maintain A Cmdoeate of Consent to ul(4naum for Workre,Compcu 302 - TUB & OR SHOWER
Orion,As provided your by Section 37M of the labor Codc,for the performance of the 303 - ROUGH MECHANICAL
work for which this permit is issued.
O 1 have and will maintain Worker's Compensation Inuuna,as requiced by Section 304 - ROUGH ELECTRICAL
37W ofthe labor Code,for Ne pcdarmanec or the wort for which this permit is issued. 305 - FRAME
My Wmk,ea Cnmpcnsution Immena carrier and Policy numkrau: 306 - HOLDOWNS
Carrie. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' 307 - INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
or las.)(thin season need Act tar complead if permit is for one hundred donars(s1W) 309 - EXTERIOR LATH
1 eenify Net in the pe,fame.m.or the work for which this permit is issued,I shall not 310 - INTERIOR LATH
employ any person in any.011e,sn sswbccomc.ubject to tW Workers Compcnssion 311 - SCRATCH COAT
laws of California.Dau
Applicant 313 - ROOF NAIL
NOTICE TO APPLICANT'.If.after making this Ccuifcate of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
Income subject to the Worker's Compensation previsions of the Labor Code,you must
.J'Z forthwith comply with such provisions or this Permit shall k deemcd evoked. 502 - FINAL PLUMBING ENERGY
ZD
Hi'te-. CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERG
aIWmh a(fmn that Unum is a construction lending ac for the formance of
>
the wurkfor which this pemtitisissued IS..3077.CivC) Per 504 - FINAL BUILDING ENERGY----
ap Urrult'aName 505 - FINAL ELECTRICAL '
>z LAaer.Aadrts 506 - GAS TEST
U 0 1 certify Net I have rad sit,application and suis that the.1bve information is
Correct.I agree to comply with all city and county ordinances and suis laws minting of 507 - FINAL PLUMBING
O
U building construction.And hereby authorize opersentilloci Of thiS City to enter upon she 5 - FINAtm�ORXS
L
I17 abwe-mentioned pmpenY for inspection purposes
(We)aster to Ove,orfindcounifyct and trcp harmless the City of Cupertino asairut 5 9 F I N is
lap liabilities,judgments.casts and capcnaa which may in any way neem.against kind City 51 !/i�
C)z APPLICACNTeof UND RSTANDSthis
AND WILL COMPLY WITH ALL NON-POINT Issued b}5 Date
4
s0 RCE#EifiXontor
Otl
�' _ � Re-roofs
gnaturt mf Appl HAZARDOUS MATERIALS DISCLOSURE Dau Type of Roof
Will the applicant Or future building Occupant nmc in handle huardous material
As def ncd by the Cupertino Municipal Code.Chapter 9.12,and the Halth and Safety
de.Section 255324)? All roofs shall be inspected prior to any roofing material being installed.
❑Ya
Will the applicant or future building oecupam Ase equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit haoinh us air conurnmAts As defined by the Bay Area Air Quality Management all new materials for inspection.
District?
0Y., J
Ihmmce Ne Wer msmamrialstequiumenuunder Chapwr6.95of Nc Califon
iliaHOINhSNctyCatic.Sccoom 23NI5,25533 en025534.1 undcrsund Nmif Nc Wilding
dos not currently have a loom Net it is my remoaibilay w Amory the occupant of the
my nus wiaAaamraccrditau,foe pJ�D3 Signature of Applicant Date
Amer or ti adred agent �6 Date All roof coverings to be Class"B"or better