03030043 CITY OF CUPERTINOvi;° " * `^" ts'�.vvzv'�?` raa-
BUILDING DIVISION PERMIT CONT CTQR INFtQRMATMO ;
BUILDING ADDRESS: ""'03030043
ERMIT NOO 3 0 3 0 04 3
gin RTRvRms rp77K R=
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M'S NAME:
PE1iMRLg °%765/2003
C GROUP (RIB
NE: SANITARY NO. CONTROL NO.
ARCH ITECI7ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION JobDescri tion
u 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing p
nz with SOOtion 7")of Division 3 of the Business end Profcaduu Code.and my license is
<K Lima to=
Daffect.affect.Class
D n nnx Claes Lk. TENANT IMPROVEMENT (.6052 SQ. FT. )
Z ar ,
f, ate Contractor
Y ARC all W use DECLARATION was p
Y 1 undcnunJ my plan Mall Ec used u public records F Il Bp R //A t1 E CI
is Licensed Pmfcuinnel
OWNER BUILDER DECLARATION ry
00 I hereby mose .(firm that 11. ucmpt from the Conkmmfs License Law for the JUL '1 ! 201j3
LI O (allowing uiemn.(Salon](D LS,construct,aluor.and me.demolish,
edOna h,or ep city Os county 1
$0 which requires•permit to quiresW alter,improve,d Permit t,or e a sig end nmment
prior m.lmmnes."Iseal to the
imapplicant for such permitm Ne Law sotemem
£���
that(commencing
punuans to the of Diatou of lW Contractor's Uceuclaw(Chape)or Sq.F[. Floor Area QI ICtJ 50 tlOn
Wo
that be s exim a Waterman
and
the
Division 3 of hic al eged Business and tion.Any vi Crede)or Ell
Nn he u emmpl thcte(rom and Ne buk for lhE alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects lite applicant in a civil penalty of 3 6'1Pt)3C"erO 0 Occupancy Type
not more thin five hundred dollar(8500).
I,uownu of the propmy,mmy emplOym with wegna utheir mkcompnuation.
will do thework,and themunum isnot interuldmortered fm ask(Sao 7044,Beat. 10i — dInspections
and Pmfmiau Cade:The ContncmrS License Law does ant apply k an owner of 10 2 - PIERS
propnny who builds or barroom Woman,and who doessuch work himself Or through his
own employees,provided brand improvements she not Intended oroRered for we.If. 103 — UFER
however,the Wilding or improvement la mid within One you of completion,the owner.
builder will ban WeWrdm of proving that he did not Wild or improve for purpose of 104 - REBAR
Lle'). 105 - ANCHOR BOLTS
as armor of the property,am secluively contracting with licensed contraemra k 106 — SEWER & WATER
rat mj(cl(Ste.7044,Business and Profusions Code:)The Comedies Lb
cc Lawdnesnor ply Wan owner.(propenywho Wilds orimprovesthemon.and, 202 — UNDERFLOOR PLUMBING
ocontncuforauc mjeco with a contrmtor(O licensed pursuant tuft Crentmithel
keno. 203 - UNDERFLOOR MECHANICAL
I aemptun a. .BA?] ,,
hb an 204 - UNDERFLOOR FRAME
WORKER'SCOMPENSATIONDECLA ION 205 - UNDERFLOOR INSULATION
I hereby affirm under penalty of perjury one of the foll.tng onat 301 - ROUGH PLUMBING
I have and will mainom is CerdRcae of Co..,m ulGiuum farwmker7 Compere- 302 — TUB Sc OR SHOWER
nation,u Provided for by Section 3700 of the labor Code.fm the pedorr mm Of the 303 - ROUGH MECHANICAL
work for which this permit is iaved.
❑1 have and will maintain Workers Compensation houromm,u required by Sedan 304 - ROUGH ELECTRICAL
305 — FRAME
3700 of We Labor CldC.for We performance of the work for which this permit is issued.
My Workera Compensation lnsumnce carie and Policy number am: 306 — HOLDOWNS
Carder: Policy NO.: 307 - INSULATION
CERTIFICATE OF E%EMP TION FROM WORKERS'
COMPENSATION INSURANCE 308 - SHEETROCK
(Ther motion=oil not W completed permit k fm as hundred dmlars(SIM) 309 — EXTERIOR LATH
Orto".) 310 - INTERIOR LATH
employ
thus In she Performanceofa work for which this permit is issued,)ernsi set 311 - SCRATCH COAT
employ any permnin any mmncrmutebaomo subjects.site Workcn'Compensation '
Laws Of CalifoMa.Data 313 - ROOF NAIL
Applicant
NOTICE TO APPLICANT.If,after making this Cenifismo Of Facmption,you should 501 - FINAL ELECTRICAL ENERGY
become mbjeco to tW Worker's Compensation provisions of the IaWr Code,you must
ozforthwith comply with such pmvkt...a,this permit mall Wdamedreversed, 502 — FINAL PLUMBING ENERGY
z0 CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
pot
4 I WtebyaRtm that there its construction lendinpgcnry lot the per(ormanm of 504 - FINAL BUILDING ENERGY
IY,> We workfor which this permit Isissucd(Sm.3097.Civ,C.) 505 - FINAL ELECTRICAL
❑.)Ga Lmdcrs rvLnc
Z) z amdraAddreu 506 - GAS TEST
UC) I certify that I ban hard this application ad soon that the ation information is 507 - FINAL PLUMBING
It, P correct.I agree to comply with all city and county Ordinances and soon laws mating to
OU building construction.and hereby adhorrise representative;of this city to enter upon ft FINAAT.' MECHAN CAL
W enov '"reed propcny for inapecu0n purposes O 9 F I N
6. (Wel rte m vve.indemnify and keep harmless site City of Cupertino againat
C)Z abilid ,3udL miscores andmmL
mpensawhich may in anywayaemm against Lid City 5 A G
o-. nPOn ANT DERSTANDS AND WILL COMPLY WITH ALL N INT Issued by:5 WORKS Date
S LATIONS.
e-roofs
Sign o(ApplicanVCOntramor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tW applicant Or future W ilding amuPanl tom or IUMk huerdou matedal
as defined by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
m1.,SONnn 1553200? All roofs shall be inspected prior to any roofing material being installed.
❑Yes VNo
Fwill the applicant or future building occupant use equipment Or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hazardous air comeminanla u dclincd by ftBay Arta Air Quality Management all new materials for inspection.
District?
❑Yes to
.,.W the bmaN"usm ntinalvcyuirommir under Chap er6.95 of the Califor.
mHell Salty Code,Scctiwu 25305,25533 and 25534.Iunameard NeH(IM Wilding
does dF'll have.NnLI,that it la my responsibility b natiry the! m n(N
tcqui a' must he met pd.,wiuuartce"fa Centro.¢oi cu a. Signature of Applicant Date If/
Ownc orauthOdrOdegcnl Date All roof coverings to be Class"Bu or better V