03030112 CITY OF CUPERTINO � R "• " -' '
BUILDING DIVISION PERMIT ie-iU"CT�OR�INFOIii tAc�oIATION
BUILDINGADDRESS: , PERMIT NO. -
ALSOER'sillegal - PERMIT MOPP
SANITARY ffAOL NO.
y
ARCHITECIYENOINEER: WILDING BUIIDINO PERMIT INPO
BLDG BLECT PLUMB MECH
Q 0 I� 0
:oo - LICENSED CONTRACTOR'S DECLARATION l Job Description
1 herehy affirm that l em licensed under previsions of Chapter 9(commencing - p
with Section 7")of Division 3 of Ne Business end Professions Code,and my license Is
in full roux end erfen.
License Class
Lec.. - ADD. '250 SQ. FT. -
Date
ARCHITECTS- DECLARATION ADD WALK IN CLOSET/ENLARGE BATH/MS .BEDRM/
1 understand my plans shall w used u public records
;o Licerucd Pmfcaslonal
OWNER-BUILDER DECLARATION
1 hereby art".that 1 em exempt fru.the Coolnnores Licenm law for the ,
0o following mean,(Section 7M 15.Business and Profession Cook:Any city or county
$ which requires permit W conateet,alter,improve,demolish,or repair any rrucrem
Sn prior.its issuance,also requires the applicant for such permit.file a signed Statement -
'p < ONMislimnsedpursuantmmeprovisionsoftheContncmr'eLkcmelaw(Chapter9 Sq.FL Floor Area Valuation
y a (commencing with Section 7")or Division 3 of The Business and Professions Code)at -
that he is eumpt therefrom and the basis fm the alleged eumptimr.Any violation of
Section 7031.5 by any appliesnt fon per.iuubjects the applicant o a civil penally of APN Number cu ane
not more Nm 500 e
Ow hundred dollars(5
). P y -
01,Asowner of the property,ormyemploymmwith miles AS their Auto compe.cellon, 35
will do the work.and the swnure is not Intended or offered for sale(Sec.7041,Business
and Professions Cade:The ComaaeWn Lt..Law data not apply W an owner of Required Inspections
property who builds or lmprowathereonnd who does uch work himselfur through his 101 — FOUNDATION "
own employees,provided that such Improvements Are not intended reoffered for tale.If. ,
however,the building or imp.wment Is Sold within one year of wmPICOO,the owner- 102 — PIERS
huildn will have the burden of proving wt he did not wild or improve far purposes or 103 — UFER-
iN1OCas owner of the property,em exclusively connecting with licensed cman ams to 104 - REBAR
nxwa the project(Sec.R144,Business and Professions Code:)no Contractors L6
.J _ ANCHOR B0L'L+.S,
cense law does not apply to an owner of property who wilds or Improves thereon,and
whocontncuforsuchp.jeebwith B&Pcfar 13 arum
contractor(s)limmdpueasntmtheCantraners lO6 — SEWER & WATER
Lt..Law.
m 202 - UNDERFLOOR PLUMBING
❑lateem les Sm .
203 - UNDERFLOOR MECHANICAL
er WORKER' M ND LA� 4.
D ON 204 - UNDERFLOOR FRAME
Iherebyaffirm under oIperjuryamofiteoilowIng Ianlonc 205 -' UNDERFLOOR INSULATION
I haw end will maintains Certificate orCmNNa toselfdnsure for Worker'sCmnKn- 301 — ROUGH PLUMBING.
nation,as provided for by Section 3700 of dm Labor Code,for the performance of the 3 0 2 - TUB & OR SHOWER
were for which this permit is issued.
❑I have and will maintain workers Compensation Insurance,AS required by Section 3 03 — . ROUGH MECHANICAL
3700 of the labor Code,for the performance of the work for which this permit is Issued; � 304 ROUGH ELECTRICAL .
My Workers Compensation Insurance envier and Policy number are:
Carrier.—Policy Na: 305 FRAME
CER11FICATEOF EXEMP1DN FROM WORKERS• 306 - HOLDOWNS
COMPENSATION INSURANCE 307 - INSULATION.
MHmwutw
aectionneedncompletadlrrmhBforme,hundreddoll.n($100)
Or less.) 308 ',- SHEETROCK -
1 enmity that in the perfomnana of the work far which this Permit is Issued,I Shall not 309 — EXTERIOR LATH '
employ any Peron in any manncrsn as to become subject to thewortee'Compcntation 310 — INTERIOR LATH
Lawsof c.lif..Ia.Data
Applicant 311 - SCRATCH COAT
NOTICE TO APPLICANT.If,After making this L'Cng1C1e of Exemption,you should
become Subject to the Worker's Compensation provisions of the Labor Code,you must 3 13 — ROOF NAIL . .
.JO forthwith comply with each provisioasorthis Permit shall IN deemed revoked, 501 .FINAL ELECTRICAL ENERGY .
Z� CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
PI hereby Niro that rhea In eo.tnninn lending agency for the performs.sof
r6> the wxrkfor which this permit aissued(Sm.3B97,Ci,C.) - 503 - FINAL MECHANICAL ENER
W^� LmdNYsNamc 504 .- FINAL BUILDING ENERG
7 z Lender's Address r.—
UO I coNfy that i hew read this application and wile dust On above lnf.mulun is SOS FINAL ELECTRICAL
ly Centel.1 Agree to comply with all city and county ordinances end sum lows elating to 506 - GAS TEST
0 U building cmustrucitor,and hereby authorize,repreammins of this city to enter upon On 0 FIN PLUMB G
W shwm
a - emfined p.peny for inspection pugroses
(We)agree W saw,indemnify and keep bar.lns the City of Cupertino against - 08 FI L
Z) liabilities.judgments,costs and expcasta which may in any way sane against AddCity
(,•)7 in consequence of The granting o this per 5
'7 APPLIC ERSTAND AND I COMPLY ITH ALL NON I Issued by: Date
Z/jSO TIO
Re roofs 514 NAL PUBLIC WORKS ,
Signature of ApplicanVCen o
HAZA A IS DISCLOSURE Type Of ROOF
Wllldmepplinma rebuilding occupant store or handle hazardous material -
as defined by Nc Cupertino unicipai Coda Chapter 9.Ix,and tiro Health and Safety .
cede. Oyu xss3z(.)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes An
Will the Applicant or future building occupant use equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
hazardous air contaminants a turned by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yea //{-�/N'n^ .
Ihawreadthehaxa ur1M1tm,¢rialsom" nBunderChpW6.95ofthecalifor-
nisl5a0h .Sec.25YJ 255 25534.1 undo thStifdc wilding
data not C a Intent.ON t re nsihly W uty u r oaupant rd the
myul Ip r ',u r Signature of Applicant Date -
Owner or authorized agent Data All roof coverings to be Class "B"or better