02110151 CPPV OF CUPER•PINO
BUILDING DIVISION PERMIT CONTRACTORINFORMATION
Buil-IdOwAlSESMORETTI DR. PERM IF N(02110151
DwbR1YA-*F:RUEDEBUSCH APPLICAI'I�N1Sl 2�'1%2 0 0 2
ION17. SANITARY NO. / CONTROL NO.
ARCH]IFCL'/ENGINEER: BUILDING PERMIT INFO
BAN] ELECT PLUMB MUCH
OCZ 0
I—a U LimnLICENSED CONTRACTOR p DECLARATION Jay
serf Innrchy antrm thatlam licensed render provisions or Chapter kommcnnng SEWER/CLEAN OTJ'1' Description
.flan
wish Scminn lIXgl) fDivisinnJof the Busin`xcc/w/nJ Profcasinns C�Nc.and myliccns is
in roll lone n tfe 'X 0 rgJp
zo Z hiycc�n�u�CP
�F —ry Iy JGI RCHITELTS RAT ON�� Y �R SYl ar'�1117� w["4h
1 understand my plans shall be used as public mends SAe�fl
0yU
LLog Licensed P..lesion..)
OWNER-BUILDER DECLARATION NOV 2 7 2002
1 hcrchy allirm Thal I am exempt from the Contractor's License Law for the $3000
no following reason.(Seen tin LS.Bairmss and Professions CrNc:Any city or county
u m tai which requires a permit m ented.U.alcor,improve,demolish,or repair any seaaam 1/ Mbn
poor In its issuance,also myuires lheapplicant lorxuch permwo lilcaxigned statement a sif
that he is licensed pursuam to the provlsonsof the Contractor's License Law chaptery 3Sdj5Fh.�ob5Ar0C Valuation
�!� (commencing with Sectio VOBI)of Division 3 of the Business and Professions Cale)or
to 3$ that he is exempt therefrom and Ne basis for she alleged Gumption.Any violation of
Section 7831.5 by any applicant for a permit subjects she applicant Io a civil penally of PPII-N Occupancy Type
not mom domfew hundred dofiars(s50) 202 - UNDERFLOOR P UMBING
❑ I,as owner of the property,me my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.70M,Business
and Prafessmns Code:The Contraears License law,aoa not apply to an owner ofth3 0 2 - TUB & quer ��.aions
property who bunds or improves thereon,and whoa«s such work foreteller through his
Own employees,provided that such improvements arc not intended or offered for sale,If, 502 — FINAL PLUMBING ENERGY
however,the building or improvement is sold within one year of completion,the owner-
builder will have the lmNen of proving mat M did not bead of improve for purpose of 506 — GAS TEST
sale.)' 507 - FINAL PLUMBING
❑ h as owner of the property,am exclusively contracting with licensed contractors to
embalmed she perfect(Sec.2044.Business and Professions Code:)The Contractors Li
ectem Law does not apply to an owner of property who beads or improves thereon.and
who Commets for mch projects with a cmntfacdor(s)licensed pursuant to the Comractor's
License law.
$rl amI craft under SSeec•�. .B&P C for this count,
O ref_ a�up!�O_Gh/ Da
WORKER'S COMPENSATION DECLARN
1 hereby allirm under penalty of perjury one of the following declarations:
I have and will mainsin a Certificate of Consent o self-insure for Worker's Com so
satinn,as provided(of by Section TRIO of the lather Code,for the performance of the
work for which this permit is issued.
L have and will maintain Worker's Compensation Insurance,as required by Section
3701 of the WMx Cmle,far the wifnrmount,of the work for which this permit is issued.
My Worker's Compensation Insumnec carrier and Policy number am:
Cartier, Policy No.:
CERTIFICATE Op EX EM PrION FROM WORKERS'
COMPENSATION INSURANCE
(This sce,tion need not becompleted ifft permit is forone hundrod dollars(51()()
nr less.)
1 cenily that in the performance of the work for which this Permit is issued.I shall nut
employ any Person in any ma It so acts hen, eso cII�eWorkers'Compensation
Laws of Calif a.Dara �(a
APPlicam
NOOSSttCCC/�O APPLICANT:I1.after making this Cef ilicae of Lxcartion,you should
becnr�gobject m the Worker's Compensation provisions of the IZMr Calc,you must
OO hmhwith comply with such Pr wi.inns or this permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
F+(4 I hemby allirm mal mere is a construction lending agency t(it he Performance of
[( r7 the work Inc which his Pcrmh is issued(Sec 30aO.Civ.C.)
W a Lender's Name
2. z IcnI Address
C.)Q 1 acnify that I have read this application and suite that the above information is
(•' cortex.l agree to comply with all city and county ordinances and Stam laws relating to
V building construction,and herebysuthorm rcprewntatives of this city to emir upon the
Uahovcmentiuned property for inspection Interests. ad
(We)agree III save,indemnity and keep harmless the City of Cupertino against
f'
liabilities.judgments,costs and expenses which may in any way accede against said City
in consequence of the granting of this Permit.
U z d by: Date
APPLICANT UN DER S"TA NDS AND WII.1,COMPLY WITII ALL NON-POINT IssuevV
SOURC GULATI S
Re-roofs
gnat cnfApplicantlCundracuar —Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant of future building occup nt store or handle harallous material
as defined by the Cupcnino Municipal Code,Chapter 4.12,and the llcallh and Safety
Code.section 255321x)'' All roofs shall be inspected prior to any roofing material being installed.
❑Yesn
Wi 1l the applicant or luwre building occupant use equipment or Devices which If a roof is installed without first obtaining an inspection, I agree to remove
emir Aamabus air contaminantsadef dM1y the Bay Arca Air Quality Management all new materials for inspection.
Diarictf
Q Yes rO
1 have lead the ham douusera erials requirements under Chaper 695of the Califon
ma Health&Safely Code,Socu ns 25515.25533 and25534.1 understand that if dm Milling
does not currently have a tenant that it is my responsibility in notify the tccuPant of de
requied nirn s •mctpi IMUWneemraCCNreaWfGeedran'c�� Signature of Applicant Date
Ownercnnauthorircdagent / , r/ /U IC All roof coverings to be Class"B" or better