03040074 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTORINFORMATION:
". 1. '
EYlb' NVf DDMADERA DR PERMIT NO,03040074
9u' Vtl* PASTUSZKA PERMITIBSUEOljl1 4/2003
E: SANITARY NUO.4 CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
0
BLDG ELECT PLUMB MECH
0 0 0
00 LICENSED CONTRACTOR'S DECLARATION Job Description
U❑ 1 hereby affirm that I..licensed under provisions of Chapter 9(commencing p
ZYW with Section 70(N))nf Division3of NC Business and Professions Cotl.,and my license is �'�
LIafullforceaaaAffect. ED
.no, LnmClan Lm.N ADD 280 SQ. FT. /UPGRADE
�t- Dau Contractor
ARCHITECTS DECLARATION JAN 1 3 2004
4 be understand my plans shall troa d public record
An.
G Licensed Professional R
S OWNER-BUILDER m Ce Contractor's
ON BUILDING
a i 1 hereby.(firm thin 1 1. exempt from the Contras Co e:Any c Law roc the
O O which
reason.(Section III31.5,Business and improve.
de lore Code:Any city nr coumy
`e m which its issuance.
e permit reconstruct,alms,impfovu h Perlia fi mash any structure
u Z i that hen ill meticpursu pursuant
to theres thovisio s o the Contractor's
Lie nse signed cm
2t- tbothcisli witpSectio7")pmvisionsoftheeBusinuriLicenseLaw ;Couldr9 Sq.F[. Floor Area 5CY®18i6ion
Vit- (eat he
xempthheefrom 7")Ofaifar oft he BminneAndmpt Professions Code)of
$ that he is exempt themfmm and or permit
far be alleged exemption.t,Any lineation of
Sectinot in than five
any
reddamforapermiuubjeeu the applicant to.civil Penalty of 32,819-No0cr00 Occupancy Type
not mom than fiv.hunam0 dollars(ss00).
❑L as Owner or the property,or my employees with wages as their sole compensation, T
will do the work,and Nemucture is not intended or offered for sale(Sec.7044,ROsioeaz - OUND4gLQWd Inspect1O0S
and Professions Code:The Contractor's License law dors not apply to an owner of .7
property who builds or improves thereon,and who doeaaueh work himselforthrough his 102 - PIERS
own employees,provided thatsuch impmwarAnm are not intended oroRemd for sale.[(, 103 - UFER
however,Ne building or improvement is sold within one year of completion,Ne ownc.
builder will have the burden of proving that he did not build or improve for purpose of
104 - REBAR
sale.).
XI.as Owner or to property,am exclusively contracting with licensed contractors to 105 - ANCHOR BOLTS
construct the project(Sec.7144,Business and Professions Code:)The Contractor's Li. 1 06 - SEWER & WATER
cerise law does not apply to an owner of property who builds or impfovaz thereon,and,
who contracts for such projects with a contractors)Imanxtl pursuanO0 the Caatracl0r'a 202 - UNDERFLOOR PLUMBING .
Lieemae Law. 203 - UNDERFLOOR MECHANICAL
❑1 HMIt2mpt under S.C. B&PC ren this rcazon
Own it
DAM 204 - UNDERFLOOR FRAME
ORKER'S OMPENSATIOND RATION 205 - UNDERFLOOR INSULATION
I hereby affirm under penalty of perjury one a e following declarations: 301 - ROUGH PLUMBING
I hors and will maintain a Certificate of Consent to self-inaum for workers COMon. 302 - TUB & OR SHOWER
within,es provided far by Section 3700 of the labor Code,far the pcAormmcc of the 3 0 3 - ROUGH MECHANICAL
work for which this permit is issued.
0 I have and will maintain Workers Compensation Insurance,as required by Section 3 04 - ROUGH ELECTRICAL
3700 of Nc Labor Code,for the puformanceof Ne.,it for which this permit is issued. - FRAME
305
My Worker's Compensation Insurance carrier and Policy number am: 305 - FRAMEHOLDONS
Cartier: Policy No.; '
CERTIFICATE OF EXEM MON FROM WORKERS' 307 - INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
or less.)'(This section need not he completed if the permit is for one hundred dollars S1W) 309 - EXTERIOR LATH
I certify thvt in the of"
f ane.of the work far which this permit is issued.l shall nut 310 - INTERIOR LATH
employ anypcfaonr mhe Workela CnmrkMaltlon ,311 - SCRATCH COAT
Laws of Calif r t U -kf ,
Applicant UN FF 313 - ROOF NAIL
INC T,IC§TOAPPLICANT. r'sCf. termnling satiothis Ceninsofcam ofExemption,ode,you must 501 - FINAL ELECTRICAL ENERGY
bac subject to the Worker's Compensation provisions of the Labor Code,you mon
Z0fort th comply with such provision or this Permit shall be deemed revoked. 502 - FINAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
I hereby offam that there is a Constnetion[coding agency Tor the perfurmance of
x > the work for which this permitisissued(Set.3(197,Civ,CJ 504 - FINAL BUILDING ENERGY
0Lenacr'sName 505 - FINAL ELECTRICAL
Zi z Lcoder'sAddress 506 - GAS TEST
J Q I certify that I have read this city
and coon and stain that Ne above ws belatiun is
y
building
uildscorrect,1 agree m comply with all city ane county ordinances and sum laws rup" re 507 - FINAL PLUMBING
�U phow-FrconswnProentl herebyfor!.,Co.. reprcxmativcs of this city m.nmrupan Nc - FINMONG
ICAL
N w .hove-memiunca property for insction purposes.
CL (We)agree to save,indemnify and keep harmless the City of Cupertino against []C� FI
tih liabilities.judgments.costs and expenses which may in any way accrue againlsaid City
in
of this
Z APPLICANTcOf the UNDERSTANDS AND TWILL COMPLY WITH ALL NON-POINT Issued by: 5 WORKS
Date
SOURCE R ULATIONS.
^ -iG Re-roofs
tgnamrc of Applic onlrscmr 6, Dam
ARGOLIS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future building Occupant stare or handle hammous material
d Acd by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cade,Section25532(.)?
0 ❑res All roofs shall be inspected prior to any roofing material being installed.
�Na
Will 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
haeardous air comaminen¢}s it III d by the Bay Amu Air Quality Management all new materials for inspection.
Dlwricri •�Ir�yj/rye,,
❑Yes
1 have mad the hasiodous materials requirements under Chapter6.95 of the Califor-
nia HcaIN ffi Safety Cods.,Sections 25505.2553)and 25¢14.1 understand Not if the building
does not currently have a ROAM,that it is my msponsiNlity or notify the OccuPant of the
reqAt ems which mustoiar niss'once
ora Cemke.to car _. Signature of Applicant Date
-
Owser authors. .Fero Date I� All roof coverings to be Class "B" or better
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