02050188 CITY OF CUPERTINO " •"
BUILDING DIVISION PERMIT CONTRACTOR INF.,ORMATION
BUILDING ADDRESS: PERMIT NO.
11387 LINDY PL 02050188
NER:S NAME: APPLICATION SUB DATE
JORIT ROM 05/30/2002
PHONE: SANITARY NO. CONTROL NO.
ARCHMCT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
a 0 0 0
�00 LICENSED CONTRACTOR'S DECLARATION
ui F 1 hereby af0nn that 1 am licensed under provisions of Chapter 9(commencing Job Description
with Section 7")of Division 3 of the Bosmeas and Professions Code.and my license is
=y imm�fnrceandcrfen. ADD 1968 SQ. FT. & UPGRADE
ONga License Class Lc.N
F F— Date Contractor qq� ARCHITECTS DECLARATION
Y+y 2< I undersand my plans shall be used as public moths
v
LL
Licensed Professional
F•—
OWNER-GUILDER DECLARATION
u 00 1 hereby.Ilion that 1 1. ,sump!from Inc Contractors :Ane Low for the
my
m—p o fallowing reason.(Section 7031.5,Business Lord rPns(ce moll Code:Any can os roomy
e K$ which requires a pewit ur construct,enter.improve,Jcmnlish,or repair any structure
w poor to its issuance.also requires the applicant forsuch permit In lite a signedmmemenl n
that he is licensed pursuant to the prnvisionsofthe Contrannr's License law(Chapler9 Sq. Ft. Floor Area yl Oatlon
�$ (commencing with Section 7")ofDivision 3 of,he Businessand Professions Csalc)or
—
that he Is exempt Ncmfrom and de basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of Occupan pe
not more than fm hundred dollar.($5110).
❑1.as Owner of the property,or my employees with wages as their sole compensation.
will do the work.and the someone is not intended or offered for sale(Sec.7044.Business
and Profwions Cadc:The Con sumes License law does not apply m an owner of 102 - P I ERS eWed Inspections
pmperty who buildsor improves theme.and whodoessuch work himselfor though his
own employees,provided that such Improvements are not inended oroReed for sale.If, 103 — UFER
however,the building or improvement is sold within one year o(completion.dm owner- 104 — REBAR
builder will have the burden of proving That he did at build or improve for purpose of
side.). 105 - ANCHOR BOLTS
1,as owner of the property.am exclusively contracting with licensed conlracmrs to 106 - SEWER & WATER
co wet the project(Sec.7044,Businw and Professions Code:)The Contractors Li-
ccnse,LawdoesnotapplytoanownerofpropertywhobuildsorimprovesNemon,and. 202 — UNDERFLOOR PLUMBING
who u for such projects wn
with econorlDprim
ant peContractor'Contractor'sLcanse law203 - UNDERFLOOR MECHANICAL
❑lam eaempl ode Sec. .B&PCfnhis leo 204 - UNDERFLOOR FRAME
r m l 205 - UNDERFLOOR INSULATION
WORKERS OhPENSATIONDECLA N 301 - ROUGH PLUMBING
I hereby affirm under penalty of perjury one of the following declarations: 302 — TUB & OR SHOWER
❑I have and will maintain a Cmdicam of Consent to self-insum for worker's Copper- 3O3 — ROUGH MECHANICAL
sation,as provided for by Section Turn of the Labor Code,for Nrmm
e pe roee of tee
work for which this permit is issued. 304 — ROUGH ELECTRICAL
❑1 have and will maintain Workers Compensation Insurance,as required by Section 3 05 - FRAME
3701 of the labor Code,for the pmfmmmcc of the work for which this pcsmit is rswce.
My Worker.Compensation Insurance carrier and Policy numhcrere: 306 — HOLDOWNS
Carrier: Policy No.: 307 - INSULATION
CERTIFICATE
IWORKERS'
COMPENSATION INSURANCE
308 — SHEETROCK
(This sectomoted Out the completed if the perm!,is ornne hundred dollars Man 309 - EXTERIOR LATH
mlCsaf 310 - INTERIOR LATH
I certify that in the performance of the work for which this Permit is issucd,I shall not 311 - SCRATCH COAT
employ any person in any manner sat as to become suhject to the Workers'Compensation
Laws of Calitnrnie.Dmc 313 - ROOF NAIL
Applicam
NOTICE TO APPLICANT:IL after making this Campeau,of Escmption, no should 501 - FINAL ELECTRICAL ENERGY
become subject o the Workers compensation pmvislons of the Labor Code,you must 502 - FINAL PLUMBING ENERGY
O z forthwith comply with such provisions or this perm it shall he deemed revoked.
zo CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
(le) hereby affirm that Nerals a construction lending agency for the Performance of 504 - FINAL BUILDING ENERGY
Ix ti the workf,,rWhich this permit isissued(Set. N7,Cr,C.) 505 - FINAL ELECTRICAL
fi7 0 Lender's Name
z Lendr,'aAddress 506 - GAS TEST
U O 1 certify that I Metrical Bor application and elate that the shove information is 507 - FINAL PLUMBING
12. F correct,I agree to comply with all city and county oMntow,and mai,laws relating m
O U buildingconswction,andherebyauNnrisrepresentativesofdimcitytocare,nounthe 5 FINAL MECHANICAL
W anove.menennedpropertyforinspectionparpons. 09 FIN
(We)agree m save,indemnify and keep harmless the City of Cupertino against 1
W IiabDldes.judgments,costs and expenses which may in my Way see=against mid City 5 N G L/
U z in consequence of Ne gnarling of this permit.
APPLICANT UNDERSTA DS AND WILL COMPLY WIT)!ALL NONE Nr Issued by51 — WORKS Date
SOU REGtl TION .
I�te-roofs
gnatu fAPp¢HAZARDOUS MATERIALS DISCLOSURE trachor Dam Type of Roof
Will the applicant or future building occupant store or handle Manors material
as defined by the Cupenino Municipal Code,Chapter 9.12,and the Health and Safety
Section 25532(.)? ..�� ((((/ All roofs shall be inspected prior to any roofing material being installed.
�Ycs blNo
Will the applicant or fntin,building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
core hazardous air contaminants as donned by the Day Area Air Quality Management all new materials for Inspection.
District'!
❑Yes No
I have real the havardnus materials requirements under Chapter 6.95 of the Califor-
hisHealth&Safety Calc,Sections 255(15,25533 and 25534.1 undcrslmd thelif building
does not rune it hose moan,that i 's my responsibility IDI nn"y the Ove rot of the
regaimme icbmu bcmntpriamsmanceof.cmrucamofQcup Signature of Applicant Date
Owner m an rind agent Dale All roof coverings to be Class"B" or better