03040065� � CITY OF CUPERT[NO '
BUILDING DIVISION PERMIT
2"2198`3°RISfiEVENS CREEK BLVD PEaMITNo.03040065
O P9`"CHING PEaMR` 64/24/2003
SANITARY NO. CONTROL NO.
ARCHIIECf/PN°INEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
loo LICENSED CONIRACIOWSDECLARATION JobDescri tion
1 1 hereby aBltm that 1 son licensed under provisions of Chapter 9(commencing P
n with Section 70M)of Division 3 of the Bodowad Rofwlats Code.and my license In
Infullfnr¢andeneck REVISION--TRUSS-CALES/IN HOUSE USE ONLY
yl�. Licene Clw Lle.t
$ °'u Contractor ARCHITECTS DECLARATION NO NEW PERMIT ISSUED, ORIG. #02060087
555 1 understand my pi.m.hall be used an public rtenrds
a Licensed Professional
b9 OWNER.BUILDER DECLARATION
i E 1 hereby of on Nn m the em accept from Contractors Li ens Law for the
0 CJ following moor.(Satre"7(DIS,Buslneas Nd Rofeatlou Cade:Any City"Wunly
ii� which¢quire.a prmll w esuctan
cnn ,alter,borrow,demolish,or repair y strym
ctu
bC Ndor in Its Issuance,also=lot=the applicant for such permit to file a dined statement
et heblicensed pursuanttothe provisions oftheConwctorsLicenselaw(Charter 9 Sq,Ft. Floor Area, VPluation
$ (Commencing with Salon 70110)of Division 3 of Mat Business and Professions Code)or
Must be b exempt therefrom and the bub fm the alleged exemption.My r1olNom of
sadom 7031:5 by any applicam fm a permit subjects the applicant m.dal penalty of APN Number Occupancy Type
not meas than Bve hundred dollar(S500).
Dl,as owner orthe property,or my employees with wagon as theirsolo compensation, 34212037 . 00
wiU&Lhemrt,andtheewctonbmtimrgdod Oroneredloesde(Sec.7M.Budmsss Required Inspections
and PmWn
feoCade The Contractor,Llceme n cww owner law dot apply an of P
property who builds Or impruwathereon.anal whodoessuchamthimsslfnrthrough his 101 — FOUNDATION
own employ..,prodded Unit such Improvements art not Intended aortertd formic.If. 102 — PIERS
however,the building or Improvement is veld within oro year of Completion,the Owner-
holder
wnerbolder will have Use burden of proving that he did not build or improve for purpose of 103 - UFER
"Ia.). 104 - REBAR
0 1,as owner of the property am onclusively ronsocting with licensed eoninnon to
connotes the pm)m(Sm 7044,Budnw.nd Profession,sex)The OMUCnmb u- 105 — ANCHOR BOLTS.
acme law does not apply m in owner of property who builds or lerprowa themon.and. 106 — SEWER & WATER
who rennets fm such pmkcu waronuacwrtO with littered pursuant to Consomme, '
License,Law. 202 - UNDERFLOOR PLUMBING
D l am mmepl under Set ,B A PC for this moon 203 - UNDERFLOOR MECHANICAL
owmn OateO 204 - UNDERFLOOR FRAME
WORKERS COMPENSATION DECLARATION
I hemey affirm under penalty of pnjoryOro of the following dalssallocsg 205 - UNDERFLOOR INSULATION
awned will melmaln.Ceofiam 0f Cement to wlf-hnum sea Waders Compo- 301 — ROUGH PLUMBING
mtlon,as provided for by Section 37M of the labor Code,for Use performance of the 302 - TUB & OR SHOWER
weak for which this permit is Issued,
0 1 hew and will maintain Weatree CompensW en Insurance,as required by Sermon 303 - ROUGH MECHANICAL
3700af the labor code,for one pdmmanceofthe wort for which this permbbwued. 304 — ROUGH ELECTRICAL
My Workers CompensNOn Insurance Caller and Policy number one: 305 — FRAME
Carder. PoliCERTIFICATE OF EXEMPTION FROM WORKERS' 306 — HOLDOWNS
COMPENSATION INSURANCE 307 - INSULATION
(",based.wed cwrc
Out be completed if the perch Is foran,hundred delan(SIM) 308 - SHEETROCK
ork")
1 ttNfy that in the performance of the work for which this permit is Issued,I shall not 309 - EXTERIOR LATH
employ any person In any Manner an as In become subject One workereCmmpewtimn 310 — INTERIOR LATH
Iawaof CJlfmmla.Dew
t 311 - SCRATCH COAT
Laws.f
NOTICE TO APPIICANP.Jr,g ur making this CeniEau of Exemption,you.hood 313 - ROOF NAIL
become ubjm w the WOrtCs Compensation provisions of the labor Code,you mud
J0 1oMwithcomply with such provision orthis Permit shall bedeemed rowtmd. 501 - FINAL ELECTRICAL ENERGY
�y
CONSTRUCTION LENDING AOENCY 502 - FINAL PLUMBING ENERGY
I.r.. Ihereby.dime dual Uers 1.a construction lemmrgagency for the prformance of 503 - FINAL MECHANICAL ENERGY
Met week
Name seawhenthtspersmubwad(sa.3w7.Cit.e.)
W Lender's 504 - FINAL BUILDING ENERGY
W Q
G ledcrs Add.
p Z505 - FINAL ELECTRICAL
U 0 I cerify the 1 have red this application and sou Net one.bow was MIdl0m 10 506 — GAS TEST
;! burrm,l.gra to comply and
all city and county ordinances and gats Jewsrupne Le
0 VR building rear
authodnnprwnutw of N4 city to enterupnlhe FIN PLUMB G
W .hove-(We)
in saw,for Wpdon pucep,h
LL (We)arra m ssw.Indemnify and trap hamclw tis City of Cupertino sgalmt 0 8 FI 2EING
AL
N Ibbitltinjudgmenu,emu andexpmn which may In any way accrue against mid City 5
V In comsequenot of ft APPLICANT UNDERSTANDS or 1AiND WILL COMPLY WITH ALL NON-POINT Issued by:5 Date
SOURCE REGULATIONS, 5 14 NAL PUBLIC WORKS
Re-roofs
Slgngure or ApplimnUConu¢tor Date 6 2 — OOF PLYWOOD NAIL
HAZARDOUS MATERIALS DISCLOSURE Type ofR '3 - ROOF BATTENS
Will ftappliant or future building scup ad gore o handle huardow material
a deRucd by the Cupertino Municipal Code.Chapter 9.13,and Uw Health and Safely 604 - ROOF I N-PROGU S S
It Code.Section 25532(.)7 All roofs shall be inspected prior to any rooting material being installed.
Dye, ONO
Will the appliausem or future building occupant uequipment or&A.which If a roof is installed without first obtaining an inspection,I agree to remove
t Mnrdous air contaminants as defied by tiw Bay Area Air Quality Management all new materials for inspection. -
7dO
Oyu ONO
I have end one hand.n oteadela rcgd mneme und.,Chmm,695 0(Ihe cati for
H"IthBSddyCde,Swd.25505,25533ad25531.1underguaUmiftc buiUing
uirements Which mug be,met poor to issuance or a CotRece or occupancy. Signature of Applicant Date
Owner or authorized agent rem All roof coverings to be Class"B"or better