03070185 CITI'OP CUPERTINO l s .r, ' +^`� ' "' - _'
ItU11.171NG DIVISION PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS: SON R CRASE CONSTRUCTION I PERMIT"03070185
'NER'S NAME: 164 GILNIAN AVE PERMIT Issue DATE
11,T_a
Lo
PHONE: (408) 370-1485 SANITARY 0. CON OLNO.
ARCHITEC'UriNGINEER: BUILDING PERMIT INFO
RLDG ELECT PLUMB MECH
Met0 0 0 0
+ 0o LICENSED CONTRACTOR'S DECLARATION Job Description
y U C 1 hereby effr liade
that 1 am nscd unr provisions of Chapter 9 Bmaromming P
<c wMSectiocall B. Diviakm3oflheBwinusps�Pmfessions cudk end my Been.is
mufnnanak L FIRE REPAIR/REBUILT FRAME/GRD UP
l2= Lim Class ` Lic.X I
��p DdLL' eU111f0
<S S ARCHITECTS OEC t.ON
m¢ undersunJ my plans shall he used in, m us
as
m.U; Licensed PmL¢cnsed Pmfessinnal
ps OWNER BUILDER DECLARATION AeH4 8 2004
1 hereby affirm that I em exempt from the Cnmranor's License Lew for the
p o following reason.(Section 7031.5,Business and Professions Code:Any city nr county
K m which reforms a Permit m construct,eller,improve,dcmnrish,or repair any xtmcmrc
prior in I%issuance.also rtyuins the applicant foe such Permit to Glc a signed sutementyu
^IC that he is licensed pursuanno the provisions of the Contractor's Liecme Law(Chapter 9 Sq. Ft. Va atlon
as (commencing with Section 7000)of Division 3 or the B morels and Professions G,de)nr
ut Nm at he is exempt Ihemfroand me basis for the attired exemption.Any violation of
a.
Section 7031.5 by any applicant for a permit subjects Ire applicant ro a civil Penalty of APN Number Occupancy Type
not more Nan Gs hundred dollars(SSW).
❑I.as owner of the propeny,or my employees with wages as their sort compensation,
will do the work.and the saucesm is net Intended or offered for salt(Sec.74aa,Business 101 — FOUNDAR+A(Kd Inspections
and Profemions Code:The Conuacurh Lice=law does not apply to an owner of
pimpeny who builds or improves thereon.and who does such work himself or through his 102 - PIERS
own employ=,provided that uch improvements are not intended or offered for sale.If. 103 — LIFER
however,Ne building or improvement is mid within one year of completion,the owna-
buuder will have the burden of proving than he did not wild at improve for purpose of 104 — REBAR
ale.). 105 — ANCHOR BOLTS
(]Las owner of the property,.B excessively contnning with licensed contractors to
ccose me Pmjcn(Sec.7twa,Business and Prolessiom coee:)'ITe Conpaaor's Li 106 — SEWER & WATER
acme law does mol appy to im owner of property who wilds sir improves forces.and 202 — UNDERFLOOR PLUMBING
who contracts for such projects with a comracutom licensed pursuant to the Contractor's
01are exempt under Sec. B6PCfor this rc
La 203 - UNDERFLOOR MECHANICAL
U 1 er . uon
204 — UNDERFLOOR FRAME
a am
WORKER'S COMPENSATION DECLARATION 205 — UNDERFLOOR INSULATION
I hereby affiant ander fertility of peyury ane of the following declacariom: 301 — ROUGH PLUMBING
❑I have and will maintain a Certificate Of Consent ro selfinmm for Worker's Compen- 302 — TUB & OR SHOWER
ration,a pmvidtd for by Section 3700 tar me Iawr code.to,the performance of the 3 03 — ROUGH MECHANICAL
work for which this Permit is issued.
❑1 have and will maintain Worker's Compensation Instrome,a required by section 3 04 - ROUGH ELECTRICAL
3700 mrthe laver code.rmn the perfmrmana arthe walk fin ween tone permGis iaued. 305 — FRAME
My Worker's Compensation lnsunna ortiv andP itynnmberam: 306 — HOLDOWNS
canner d n) p ey aO0-?� 11 -C
CERTIFICATE OF EXE ION FROM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
rat lc::)(this section need nor he eompleadcmif the Permit is for nhundred dollars(S I m) 309 — EXTERIOR LATH
1 ecol y than in the prifoom nee or the work for which this permit is issued,I shall not 310 - INTERIOR LATH
employ any Person in any manner sit as In become subj=1to the Wmkcra''Compensation 311 - SCRATCH COAT
laws mrcafiannia.Date
Applicant 313 - ROOF NAIL
NOTICE TO APPLICANM If,aper making this Certificate of Exemption,you should 501 — FINAL ELECTRI CAL ENERGY
Became subject to the Worker's Compensation provisions of the horn Code,you must
�Z forthwith comply with such provisions or this perm it shall be deemed munked. 502 — FINAL PLUMBING ENERGY
?O CON STRUCION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
F� `M Ihmchyaffirmthrort eisaeomtruainnlcudinga,camy lm the performance of
'Y > the work fur which
this permitisissued(Sec.305D.Co,C.) 504 - FINAL BUILDING ENERGY
i p 12ndcr's chain 505 - FINAL ELECTRLG
= Z Lemder'sAddress 506 - GAS TEST
U p 1 cenify mal r have read this aPpliemma and State that the above information is 507 — FINAL PLUMBI
comet.1 agree m comply with all city and county ordinances and sate laws relating to
building construction.and hereby moor sae repfesematise of Nis city to enter upon the
`OU above mentioned pmpmy for impaction purposes, FIN MEC
(We)asac m ave,inticmnify and keep haemlea me City of Cupertino against 0 9 F I
Vy Intel lilies,judgments,costs and expenses which may in any way accrue againauaid City
U,`� in ttmuymencc of the gmnlins ill this permik 5 APPLICA UNDER TANDS AND WILL COMPLY WITH ALL NON-POINT Issued bY:5 Ca e
SOURC' ULA NS.
/H/—J/�L,!�///
�� Re-roofs
si c or Applianvcomr c Dart
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Wi11 the appticam nr future building n ocuPam one or handle harmdmo materiel
tleGned by the Cupertino Memel skc.Chapter 9.12,and the Health and Safety
dc.Section 255320)? All roofs shall be inspected prior to an roofing material beim Installed.
❑Yea Nm P P Y g $
Will the applicant or future wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air cnnmminants a define by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Ycs �I
Ihavc mcheaardnusmateria.2553ircmcn¢34.1. dcap 6 lifthc Cald,ng
isr Olt c Code.Seeuum 25 15.255)]and 255J<.IuWersuntl thmifthc wilding �/
Jrcc Olt to have e tenan tis sPtmslbllity ill nasty om nimupanl of the
requ m chmmstbcm tut mnracemfirteof tuPan S1 ureofApplicant `� Date
Owner uthornad agent pea
All roof coverings to be Class "B" or better