03070215 CITY OF CUPER't'INO .....Wty
BUILDING DIVISION PERMIT CONTRACTnRINTORMATION
BUILDING ADDRESS: SYL-MAR CONSTRUCTION PERMIT NO03070215
&2R'S NAME: 1310 TULLY RD. # 114 PERMIT ISSUE DATE
UITY OFFICE
PHONE: (408) 293-7969 SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELER PLUMB MECH
±00 LICENSED CONTRACTOR'S DECLARATION Job Description
I '1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing p
with SectinYe))of Division 3 of the Bound Professions Code.and my license is
a. in full force d cif Z1 /J p�
i�? License m LIc.N !/ TI--EXTERIOR �'11INVIA .E®
p
Data C° no
7W
f u
" me "IundcrstnJmyplana¢hallhcused
JOU JAN 1 qq D
O4
eo�9 Licensed Professional
,5 OWNER-BUILDER DECLARATION
S I hereby affirm that 1 am exempt(rum the Contractor's License Law for the - BUILDING
'� �S'(�,�w
0O fallowing mason.(Section 7031.5,Business and Protasions Code:Any city or county L D• NG
Z
S V which rcquiws A pewit m construct,alcor,improve,demolish,or repair any structure
° prior m its issuance,also requires applicant for such permiuo file a signed Abutment
MIbarbeislicensedpursuanttothepmvi.ionsofthcCOntrocm'sGianseLaw(Chapter9 Sq. Ft.Floor Area Valuation
(commencing with Section 7000)of Division 3 of the Business and Professions Cade)or
$ Net he u exempt Ih nafmm and the basis for ft alleged exemption.Any vi.hown of 31618035 . 00
Section 7031.5 by any applicant for a permitsubjects the applicant to a civil penalty of APN Number - Occupancy Type
re N
not more firs hundred dollars(5500). - -
❑1,stowner of the pmpeny,Mary employee.with wages u 111e31301e eompema0on,
willdodNwmk.asdthe.muctutei...t intended M.ffcred formic(Sec.70M,Business iui —
And Prafcvimu Coes:The Contractor.Littre Law door apt apply m an owner of 102 - PIERS
d Inspections
pmpcny who builds or improves llemon,and who docssuch work himsel(of through his
own employees,provided that such improvements are not intended o,offered!areal:.If. 103 — UFER
however,the building or improvement Is mid within one yew of comPIAdon,the owner.
builder will have the burden of proving that he did not build or Improve for pury of 104 — REBAR
"I`)' 105 - ANCHOR BOLTS
0I,at owner of the property,am exclusively contracting with licensed convacmrat9 106 - SEWER & WATER
convect the project(Sec.7044,Business and Professions Code:)The Contractor's Lt
came law docs not apply to an owner of property who builds or improves themon,and,
202 - UNDERFLOOR PLUMBING
License Law•eu for mm
r such projecwithaeOnorU)liccnudpur¢uam ere to Contractor's203 — UNDERFLOOR MECHANICAL
❑ Iamexempt louder Sec. BkPCfor this mantra 204 - UNDERFLOOR FRAME
` Date 205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION
I hereby M.until,penalty of perjury ON of tha following declafatiam: 301 — ROUGH PLUMBING
ar .
❑IhawandwillmamminaCeniremeofCoMenttoZAIN�aeforWormracampen- 302 - TUB & OR SHOWER
station,a provided for by Section 3700 of the labor Code,for the performance of the 303 - ROUGH MECHANICAL
work for whish this Pcmnit is issued. 304 - ROUGH ELECTRICAL
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 or be labor Colic.for the performance of the work for which this permit is issued. 305 — FRAME -
MyWorter.Cnm enulionlnwnnceartic ane Policynumkra OL 306 - HOLDOWNS
307 - INSULATION
CERTIFIC NSA PITON FROM WORKERS'
COOMPEMPE NSATION INSURANCE 308 - SHEETROCK
or Rhissecd°n Med sotbeCompleted if be Permit I.for one,hundred dollars(slro) 309 — EXTERIOR LATH
I Certify
310 - INTERIOR LATH
employ certify Nu lir plc performance of the work fm which this tat W rl iuucd,I shall not
Law,o any person in any manncnnazln become subject to Workcn'COmpcnsation 311 - SCRATCH COAT
Laws of cafiramia.Date -
Applicant 313 - ROOF NAIL
NOTICE TO APPLICANT:If.after making this Certificate of Exemption.you should 501 - FINAL ELECTRICAL ENERGY
become subject to the Worker's COmpensatios previsions Or the Iatt r Code,you must
_,z forthwith comply with such provisions orlhispermit shall bedeemed rtv°ked. - 502 — FINAL PLUMBING ENERGY
z CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
IhembyafirmNat thereilisissucd(Scc.Ji.aeomtrwtinn lending agency lnr the Perfurman^sur 504 - FINAL BUILDING ENERGY
5> Naurwhich
dc,'a mispctm097.Civ.CJ 505 - FINAL ELECTRICAL
31 Q Lender's Name ,
z L ndctSAddrcrs 506 - GAS TEST
1 cenify that 1 have read this application and stem the,Ne show infomssties is 507 - FINAL PLUMBING
y F' collect.)gree to comply with all city and county OWMA lies ON stale laws relating to
J U building convection,and hereby auNorim representatives or this city to enter upon the JFIN MECHAN CAL
about-mentioned pmrs'rty for inpection purposes.
(We)ague to save,indemnify end keep harmless the Coy of Cupertino against O 9 V) Iiebi lilies,judgments,emu and eapemu which may in any way accrue against mid City 5 NG
U z APPLIICCANTeof fire UNDERSTANDSthis
AND WILL COMPLY WITH ALL NON-POINT Issued by:5 WORKS Date
SOUR RFGULAT
Re-roofs
nature Of ApplicaHIce
HAZARDOUS
US MATERIALS DISCLOSURE Type of Roof
Will due applicant ur future Wilding Occupant Chapter
nam2,handle Health uAmalarial
az defined by the Cupeninn Municipal Code.Chapmr 9.13,and the Health end Safety
Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ).b
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'
emit haiardous air contaminants as defined by the Bay Arta Air Quality Management all new materials for inspection.
District9
❑Yea Nn
1 h¢w mad the huaNtnts mucrials rtyvirtmcnts untkr Chapter 6.95Of rte Cali(or
nice Hextut 6 SafetyCode,ge vom 25N15,25533 and 25534.1 umk,sund Nw i(Ne building
dors not cufmuly how A tenant out it is my maponionty,m sorry the..Parr of Ne
myuirc c swhichmustpc clpduru,,m.anccof.Ccnlficamo( ° [y. Signature of Applicant Date
a,or aumo,irdagent Dale All roof coverings to be Class "B" or better