03060146 CITY OF CUPEwrINOA° l* �
BUILDING DIVISION PERMIT CONTRX6T0R INFOTiMATIQN
BUILDING ADORERS: PERMIT NO03060146
.
OWNER'S NAME: PERMITIESUE DATE
E: SANITARY NO. CONTROL NO.
ARCHITEMENGINEER: BUILDING PERMIT INFO
BLDG ELECT LO O
IO, LICENSED CONTRACTOR'S DECLARATION
eeO Ilu.byaffm that lam ficemcd under previsions of Chapter 9(cammctuarS - Job Description
with Sectionand of of Divixion J of Ne Ousinus and Professium Code.and my limnse is
.�1 Or in full forte and effect.
iq: Lice.seelass Lica REVISION--GENERATOR-IN HOUSE USE ONLY
ere Date C.m,ae.r NO NEW PERMIT ISSUED/ORIG. #01070021/#03010050
ARCHITECTS DECLARATION
I undcCund my plens.hallbo..it as public Canada NO FEES--PER NANCY/VERA
a G Licensed Professional �^
R 3 OWNER-BUILDER DECLARATION
9<f 1 hc.hy air,.that I am¢tempt fru.me CmidnetoYs License Law for the
COO following Lesson.(Section 7031.5,Business and Profeaions Cole:Any city or county
which requires a Permit to c.natruc6 alter,improve.demolish or repair any structure
52<
PH.,in its naumet,'.lao.quimaoWapplicmt fm.U,h permit.flea.igncdn,...at
£ that he is licensed pumuanuo the pmvisinv of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area llrltt
(commencing with Section 70110)(rf Division]of the Business and Pmfeaimn Cmle)or C
y $
that he is ssemrefr
p,therefrom and the basis for the alleged cmmpBO..Any violation of $0
Section 7051.5 by any applicant for a permit ubjects the applicant.a civil Penalty Of APN Number Occupancy Type
not.ore than five hundred delta,,IS500). 36901029 . 00
❑1,u owner of the pmperty,or my employees with wage.u their solo compensation,
will do the wad,end to.structure Is not intended or offered for said(Sec.7014,Business
and Professions Code:The Convector's License law doeit not apply to an owner of Required Inspections
property who build.or Improves thereon,and who doessach work himself orlhmogh hit
own employees,provided that such Improvements are not intended orartered formic,If,. 101 — FOUNDATION
however,the building or improvement Is told within one year of completion,the owner•
builder will have the burden of proving that he did net Wild or improve for purpose of 102 — PIERS
ate')' 103 - UFER
�fltp./1a owner of the property,am exclusively convecting with licensed Comore s to
ame,the project(Sec.7044,Business and limitations Caee:)The Conuutor.Li. 104 — REBAR
come law docs not apply to an owner of property who Wilda or improv theme ,and 105.5 — ANCHOR BOLTS
who carousels for such projects with a contractor(s)licensed Pursuant to the Contractor's
LimmUCUw 106 - SEWER & WATER
❑Ion cacmpt under5 ,B&PC nisi recta. 202 - UNDERFLOOR PLUMBING
203 - UNDERFLOOR MECHANICAL
WORKPA'S OMPENSATION OECLARATIO
I herebyatr,m uneer penalty of perjury one of the fo0owing declvations: 204 — UNDERFLOOR FRAME
❑Thim and will maintain Cenifuamof Cnnuulcnsum
nOsefor worteb Compcn, 205 — UNDERFLOOR INSULATION
¢tion,as pmvided for by Section 37M of the labor Cotte.for the Performance of thc 301 - ROUGH PLUMBING
work for which this permit is issued.
C]I hats and will maintain Worker's Compensation Insurance,as mquimd by Section 302 — TUB & OR SHOWER
37M or the labor Casio,for Ne pmformancc of the work for which this Permit i,issued. 303 — ROUGH MECHANICAL
My WOrlece ompenad . .so e a PoNyrounkrare: 304 - ROUGH ELECTRICAL
Gmicr:
Policy No.:
CERTI A •OFEX ON FROM WORKERS' 305 — FRAME
C IPENSATIONINSURANCE 306 - HOLDOWNS
This=am wed not an completed if be remit is for ane hundred dollan(5100) 307 INSULATION
prksa) - 308 - SHEETROCK
employ certify Na ter rise n afnrmancc of the wad fm which this permit rl isswe,I shall not
Laws of
in any manncranuto become subject the Werken'Compcmadon 309 — EXTERIOR LATH
Laws ter California,0.0
Applicant 310 - INTERIOR LATH
NOTICE TO APPLICANT:If.after making this Cenifinte of Exemption,you should 311 - SCRATCH COAT
become suhjml,r be Worker;Compensation previsions of the labor Coda you must
.J Z forthwith comply with such provisions or this Permit shall W deemed mvokee. 313 — ROOF NAIL
y O CONSTRUCTION LENDING AGENCY 501 - FINAL ELECTRICAL ENERGY
zfu�which anthat there isacomtructionlending agency,for the performance of 502 - FINAL PLUMBING ENERGY
> the work
]q Lender',Namc Permit 503 - FINAL MECHANICAL ENERGY
7Z
Lender's Aeema 504 - FINAL BUILDING ENERGY
U O 1 cenify Net I have read this applies,;..and .in inn an,above infmmaiun is 505 FINAL ELECTRICAL
D(~ correct.l agree to comply with all city and county ordinances and atsle laws add ing to
U building construction,and hereby authorim Cprmentnives of this city to enter upon the GAS TEST
W ahovc(We)are properly for Impaction purposes.
(We)agree to ave,inecmnify and keep harmless,he City or Cupcnino.gai.n 0 7 FI
i.v f�j1 liabilities,judgmcnu,costs and expenses which may In any way accrue agslnn aid Ci,y 5 p
AL
U in consequence of the granting of this Permit.
ti APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: 5 Date
5 CE REG�CLA ONS.
Signad.rd Applican mums Date U3 Re-roofs 5� 4 INAL PUBLIC WORKS
H ARDOUS MATERIALS DISCLOSURE Type of Roo
Will the applic our future building occupant store or handle haardaut material
as defined by dm Cupertino uniciipal,Code.Chapter 9.12.and the Health and Safely
irendt]Ye,s.Sectio.15572(.)1 All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment or device,which If a roof is installed without first obtaining an inspection,I agree to remove
aa
It hNa ous air contaminants deface by the Day Area Air Quality Management all new materials for inspection.
'is,ric,T
Cl Yet
I hem reW Nc harsh ama.rials requirements under Chepur 695afde out
ifor-
oia H.10 gr Safety Code,So d.25505.255JJ am125534.1 umkCund Last if t e Wilding
daa an currently have a ammL that i,is my Cspomibibly 0 notify tbe.ttuPmt of rise
C,
wine o Wmet b, Bane or n;ncam or Occu r Signature of Applicant Date
NR
Own.,.1..thurimd.s t I Data All roof coverings to be Class"B"or better