02100016 (2) CITY OF CUPERTINO "`
BUILDING DIVISION PERMIT ,,-CONTRACTOR INFORMATION:„
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BmLp1aG 19"PHAR LAP DRIVE HIGHLAND CONSTRUCTION AND IBIINP71tfR0WV2SU1g0A0sP0016
R3FTIER, GILLIAN 20073 NORTHCREST SQ APPLICATII / ®L/ 2002
NF:: 4082411858 SANITARY NO. CONTROL NO,
ARCIR ECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELELT PLUMB MECH
�Opp LICENSED CONTRACTOR'S DECLARATION
Ihcrchy ef.Nal l am licensedunder prolamosof Chapter 9(commencing FOUNDATION/RE'll h�p�q. `ITT"
with Section 7(n)),fDivision 3ofNe Business and Professions Code.and my license is
in fallNmeandeffect. BATH/SHEAR WALL UPGRADE
License Class Lic.g
CZF, LicenseO Dam Conuactm
ATION
< 1 understand my plans Alit M used as public l c nourds
roOO3te� Licensed Professional
F W O t OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the / J
0 following reason,(Section 7031.5.Business and Professions Code:Any city or county
which requires a permit to construct,alter,improve,demolish,or repair any structure 3 750
i prior it)iLL issuance,also requires the applicant for such Permit o file aligned statement
S�pZ< Nal he is licensed pursuant o the previsions of the Contraclor's License Law(Chapter 9 Sq. Ft. Floor Area Valuatt011
N�to (commencing with Section Nail)of Division 3 of me Business and Professions Code)or
$ met he is exempt thcmfrm tend me buts for the allege)exemption.Any violation of 3 2 6 3 9 0 2 8 . 00
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of APN Number Occupancy Type
not more man five hundred dollar.(S5f10). 101 — FOUNDATION
❑I.uowrmr of the Propery,or my empleyeea with waguu Meir sole compensation,
ptinn
will do me work.and me secturo tsnol intended or offered for set.(Sm.7044,Business —
and P..feal Code:77te Contractors License Law dose not apply to an owner of 10 3 - UFER Required Inspections
property who Wild..,improves thereon,end whodcea such.,it himself.,through his
own employees,provided that such improvements are not intended oroRered for sale.If, 104 — REBAR
however,be building or improvement is sold within one year of completion,me owner.
builder will have tbe burden of proving Nat he did not build or improve for purpose of 105 — ANCHOR BOLTS
MIe) 106 - SEWER & WATER
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to 202 — UNDERFLOOR PLUMBING
consent me project(Sec.7044,Both.and Profeuiom Code:)The Contractors Li-
cure Law does not apply toanowner o(property who Wilds orimVroseathemon,and, 203 — UNDERFLOOR MECHANICAL
who contracts for such projects with a contractor(s)licensed pursuannu me Contractor's
License Law. 204 - UNDERFLOOR FRAME
I am exempt under Sec. .B&PC for this rouon 205 - UNDERFLOOR INSULATION
neo Date 301 - ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION 302 - TUB & OR SHOWER
I hereby affirm under Penalty of perjury one of me following deelaraens: 303 - ROUGH MECHANICAL
have and will maintain a Centlfd
incate of Consent to semum for Worker's Comber. 3O4 — ROUGH ELECTRICAL
tion,u provided for by Section 37W of the Labor Code.for me Performance of the
work for which this Permit is issued. 305 — FRAME
❑1 have and will maintain Worker's Compensation Insurance,az required by Section 3 0 6 - HOEDOWNS
31.)of me Labor Code,for me performance of the work for which this pm an is issued.
My Workers Compensation lmuerm,carder and Policy number art: 307 — INSULATION
Carrier: Policy NO.: 308 - SHEETROCK
CERTIFICATECOMPENSATION IINSURANCE ON OORKERS' 309 — EXTERIOR LATH
(This section need not In,completed if the permit is linin,hundred dollars D 100) 310 - INTERIOR LATH
nr1Cm.) 311 - SCRATCH COAT
I unify mat in the Performmce of the work for which this permit is issued.I hall not 313 - ROOF NAIL
employ any person in any manner so u to become subject to the Workers'Compensation
Laws of C.Idmnla.Date 501 - FINAL ELECTRICAL ENERGY
Applicant
NOTICE TO APPLICANT:If.after making this Ccrilluto of Exemption,you should 502 - FINAL PLUMBING ENERGY
become subject to the Worker's Compensation provisions of me Labo,Code,you mon 5 0 3 - FINAL MECHANICAL ENERGY
Oz forthwith comply with such provisions or this Permit shall W deemed revoked.
zo
CONSTRUCTION LENDING AGENCY 504 - FINAL BUILDING ENERGY
.Nn
[r I hereby alOfm construction mere is a consction lending agency for the arriarroncrof 505 - FINAL ELECTRICAL
L4' 7 the work fnrwhich this permit isissued(Sec.3097.Civ.C.) 506 - GAS TEST
W Q Lender's Name
n Lander'sAddreas 507 - FINAL PLUMBING
UO 1 unity that 1 have read this application and stem that the above information is 508 — FINAL MECHANICAL
W fircorrect.I agree to comply with all city and county Ordinances and sum laws rolning to
Wilding construction.and herchy authame mprosentathu of this city to crime upon the 5 FINAL GRADE
Wshove-mentioned property for impecen purposes. 1 O F I N
tF+y' 4 (We).,me Iu save,indemnify and keep harmless me City of Cupertino against
h liabilities,judgments costs and expenses which may in any way accroe against said City 5 N WORKS
V z APPLICANTeof the UNDERSTANDS Athis
ND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
sign.ruro of ApplalmoConuactor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant nr future building Occupant store or handle baverlous material
efined by the Cupeninn Municipal Code,Chapter 9.12,and the Dulth and Safety
.Section zss32(e)?
❑Yes ❑No All roofs shall be inspected prior to any roofing material being installed.
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
1 havardnus air contaminants as delined by the Bay Area Air Quality Management all new materials for inspection.
strict?
❑Yes C3 NO
I have mad the hazardous materials rtxluimmems under Chapterii 95 of the Califor-
nia Health At Safety Cale,Suba.25505,25533 and 25534.1 understand thatif the building
Jens not currently have a tenant,bar it is my responsibility m notify the Occupant Of the
mquiremcnts which must be met prior m comm,ofa Certificate of Occupancy. Signature Of Applicant Date 4
Owner or authnri.c!agent Dam All roof coverings to be Class"B" or better
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