02110124 (2) CITY OF CUPERTINO +" A r, +
RUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUB. .n )RRAI NB0W DR TIMELINEvCONTRUCTION PFRMTNT2110124
owNYMIDEAN1AUSTIN 14589 S BASCOM AVE APPLICATITN151R /
T/2002
ZONE: (408) 356-1790 SANITARY NO. / L CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MP.CH
I� 0
00 LICENSED CONIRACIOR'S IJIiCLARAI'ION
hcmbyafrmthat lamlactated undcrpmvisionsnfChapmr9(urmmcndng MINOR KITCHEN 'IPt f5TY AS RANGE
with Section 7(XX1)of Division 3 of the Business and Promssions Cole,and my license is
in leof n lime and d(Nal /n
0 Liccne Cl ss__� Lic.N 9.�- tI
<F_—� Dale 10 Lin
ARCI IITI:CrSD1�CLAl ION ����L7rnvq
K 1 understand my plans shall be used es public cords
ppw
u.t; LimnsedPromsmona' DEC 2 3 2002
F�•�j OWNER BUILDER DECLARATION
f1 hereby affirm that 1 am exempt from the Contractor's License Law lin the $2000
rc o O following reason.(Session 8)31.5.Business and Professions Coale:Any city or county
a'N$ which requiresa lKrolil ser construct.alter,improve,demolish.(it repair any structure
w prior at its iasaanec,also mquims the applicant for such pssmiuu life a signed statement
tt
fisc that he isImensedpursuanothe provision,ofthe Contractor'aLicense Low lChapler9 3 2M Valuation
m� (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
a 3$ that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 8031.5 by any applicant for a permit suhjecls the applicant to a civil penalty of PN'N Occupancy Type
not mom than five hundred dollars(SY10). 102 - PIERS
❑1,az owner of the property.or my employees with wages m their sole compensation, ±E)3 TJFEtt
will do the work•and the would.is not intended he offered for sale(Set.7W.Business
and Professions Code:The Conoaclor's License Law docs not apply to an owner of 104 - REBAR Required Inspections
property who builds or improves therein,and who docs such work himself or through his
ton employees.provided that such improvements are not intended or offered for sale.If. 105 — ANCHOR BOLTS
nnweveo the building or improvement is cold within one year of completion,the owner. 106 — SEWER & WATER
builder will have Ne burden of proving Wal he did not build or improve for purpose of
safe.). 202 - UNDERFLOOR PLUMBING
❑I,as owner of the pmpcny.amexclusively conuaa;ng wit Licensed contractors to 203 — UNDERFLOOR MECHANICAL
construct the project(Sec 1814,Business and Professions Code:)The Conoacmr's Lb
erne law does not appy to an owner of property who Wilds or improve.,thercom and 204 - UNDERFLOOR FRAME
who contracts for such Amn
jects with a conacmr(s)licensed pursuant to rhe Contractor's
LicenseLaw. 205 — UNDERFLOOR INSULATION
I am exempt under Sm. .B&P C for this reason 301 - ROUGH PLUMBING
owner Date 302 - TUB & OR SHOWER
WORKER'S COMPENSATION DECLARATION 303 — ROUGH MECHANICAL
I hereby affirm under Penally of Perjury one of the following declarations: 304 — ROUGH ELECTRICAL
I have and will maintain a Certificate ofConsent to self-insure for Workers Compere 3O5 — FRAME
sation,as AmvWcd for by Section 38X1 of the labor Code,for the Performavac of the
workmrwhichOi,Neai,isissued. 306 — HOLDOWNS
❑I have and will maintain Worker's Compensation Insurance,as required by Session 3 07 - INSULATION
3700 of the Labor Code,for the performance of the work for which this pe 't is issued.
My Worker's C/ao�m�p�e/nsation Insurance carrier and PolicyI n�futemfnberranam4Q:�'sVl✓K 308 — SHEETROCK
wrier:STkleIF9U & POIIcyNo.Yy_a6r- 6Jb 0406 309 — EXTERIOR LATH
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 310 - INTERIOR LATH
(This section need not W completed ifthc permit is foronchundred dollarin)(10) 311 — SCRATCH COAT
,it less.) 313 — ROOF NAIL
I codify lhn to he pedurmane,of the work for which this Permit is issued.I shall not 5 01 - FINAL ELECTRICAL ENERGY
empluyany pp< in any mu roras t become subject the Workers ComPensalinn
Law,ser carr/J t(inn nd7paWn _'� 502 - FINAL PLUMBING ENERGY
nnN;cam
NOTICE TO PL CANS:If,after making this Cenilicam of Gxcmption,you sbnuiJ 503 - FINAL MECHANICAL ENERGY
become
hit, to Worker's Compensation powism,of the Labor Colt.you must 504 — FINAL BUILDING ENERGY
O 0 forthwith comply with such provisions or Ihia permit shall he deemed revoked —
z CONSTRUCTION LENDING AGENCY 505 FINAL ELECTRICAL
[-. Na I hereby affirm Wal Barrels a construction lendingagcncy for the Performance of 506 — GAS TEST
Ci > the work for which this Permit isissued(See.31W7.Ce.C.) 507 — FINAL PLUMBING
!I] Qcorrects Namc
z LendersAddress 508 - FINAL MECHANICAL
U O 1 codify that I have read this application and sw¢that the shove infmmmion is 509 — FINAL GRADE
lL curtest.I agree las comply with all city and county ordinances and some laws relating
U
OU holding conslmctinn,anJhereby authnrimmprescmalivesnlthixciymenmrupopnnthe 5 FINAL PLANNING
} W wove.menuoned PmPcdy for inspection purlwses. _ 14 FIN I WORKS
(We)agree m slave,indemnify and keep harmless the City of Cupertino against
F" lobililk,,jmlgmcnu,cosu and cspcnus which may in any way assents against said City 't
U inconsectsome of the grantingof,hi,permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON POINT Issued by: Date ZS
-
Sm 10 S. /
e . / 11�� Re-roofs
Signet p�favector Ua
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
II We applicant or future bei Wing occupant Stoic or handle Health
Safet l
az defined by the Cupedino Municipal CoNe,Cbapmr 9.12,and the Health and Safety
Im.lCude,Section 255321m7 All roofs shall be inspected prior to any roofing material being installed.
�Yca 0 N
Will thea applicant or future building occupant useequipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
pP g by theo
milia? nusair cnmaminan6asJcrncJbytheBay arcaAir Quill gManagement all stew materials for inspection.
District?
❑Vcs 7 N
1 have read the hamadmis materials requirements untkr Chapter 6,95 of the Califoo-
iialf"Ith&'wcry (rk.&,ctions255O5,25533md255.4.lun&r,u dJ ati[Wehuildiag
does arty have atedut.Wal itis myresponelbiliywnotify the oxcu ant of the
requ;r Lw ' tmalmmpmuWiaaum,eenracertmcamuf =p Signature of Applicant Date
I l l0 0'1.
Owner nt thmi ¢agent Date All roof coverings to be Class "B" or better