02110058 (2) CITY OF CUPERTINO ',,�-a xr-n "'
BUILDING DIVISION PERMIT CQNTRW T0"NF'16,* IONS
pulONOORBSULTS WAY TAYLOR WOODROW PERMIT N02110058
ThYlkOR WOODROW #10120 IMPERIAL AVE. APPLIcAoT?1syUOTY2002
PHONE: SANITARY NO. CONTROL NO.
ARCI IITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o t�
�00 LICENSED CONTRACTOR'S DECLARATION
I hcrch firm that I am licensed under provisions of Chapter 9(commencingc ft
�0 wins ection 7101)o(Division 3 ofthe Busincuand Pra(cui...Code,andmylicenseREVISION-BETA WHLLS
�� in fullferceinicrfea IN HOUSE USE ONLY, NO NEW PERMIT ISSUED
FNq: D,nenwa.a Corse ORIG. #02030201
rq Dam TS DECLARATION
aYC¢¢ ARCHITECT'S DECLARATION
C a 1 understand my plans shalt be used as puM1lic records
SpnO
LLokd Licensed Professional
j OWNER-BUILDER DECLARATION
fy. P 1 hereby of.that I em exempt from the Contractor's License Law for the
i 6
QJ which re mens a (Section Rp13,Business and Professions demolish,or:Any city ns county
which requires a permit re cores the alley,improve,hPermittor repair any statement poor u,i¢issuance,also requires she applicant lar such permit m files signed uatemcm
�Z<
that rearieccnwit pursuant in the provisions nfine Contractors
eti License Law Charlie,Code)Or Sq. Ft. Floor Area �AI�IIl10❑
¢2$p p (cam a is exempt therefrom
Section and of tons for she
the alleged
case PmfAnyvi Cnde)of
y 3� mot he is exempt merefrnm and Ne basis for Ne alleged eumption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
not ore Nan five hundred dollars(5500). Occupancy me Occupancy Type
❑1.ant owner f Ne impiety,or my employees with wages as their role compensation. 3:193: Febi
will do the work,and the structure is Out Intended nr Offered fee sale(Sec.7044,Business
and Professions Code:The Conuacum'x License Law does not apply to an owner of 102 - PIERS equ3red Inspections
property who builds or improves thereon.and who does such work himsel f or through his
own employees,provided that such improvements are not intended or offered for mic.It. 103 — LIFER
owever,the building or improvement is sold within one year of completion.the owner. 1O4 — RE BAR
builder will have the burden of Proving that he did not Wild or improve for puaese of
sale.]. 105 - ANCHOR BOLTS
01.as Owner of the property.am exclusively contracting with licensed contractors no 106 - SEWER & WATER
construct the project(Sec.7104.Business and Professions Code:)The Contractors Li-
ceLaw due.be,apply to aowner ofproperty wheWild.orimprove.thereon,and, 202 — UNDERFLOOR PLUMBING
who contract for such projects with a carnations)licensed pursuant o the Contractor's
License Law. 203 - UNDERFLOOR MECHANICAL
❑I am exempt under Sec. ,B&P C for this reason 204 - UNDERFLOOR FRAME
40 mer Dare 205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATIONDECLARATION 301 - ROUGH PLUMBING
I hereby.Bron under penalty of perjury one of the following declarations: 3OZ — TUB & OR SHOWER
❑Ihave and ideforby eCen3700ofeomamrosede,fore for
PerformaCooper-
eofthe 303 - ROUGH MECHANICAL
talion,as provided for by Section 37111 of the Inhnr Code,for the performance of she
work for which this permit is issued. 304 — ROUGH ELECTRICAL
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3 05 - FRAME
37110 of We Labor Code.for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Polity number are; 306 — HOLDOWNS
Cartier: Poll,No.: 307 - INSULATION
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 308 - SHEETROCK
(Thisareinnnned notbacompletedif ran permit is for one hundred dollars I$IW) 309 - EXTERIOR LATH
orbital 310 - INTERIOR LATH
1 certify that in the performance of the work for which this permit is issued,1 shall not 311 - SCRATCH COAT
employ any person in any manner m subject as it become subjeco to Workers Compensation
Laws of Cilifomia.Date 313 - ROOF NAIL
Applicant
NOTICE TO APPLICANT:I f,after making this Ccni Etude of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become subject ht the Worker's Compensation provisions of the Labor Code,you must 502 - FINAL PLUMBING ENERGY
Oforth comply with such Pro visions nr this perm itshal l M deemed revoked.
z CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
( Iherebyaftirmthatmereisaconswctionlendingagencyfortheperlmiromccof 504 - FINAL BUILDING ENERGY
kY > thcwork for which this permitisissued(Sec.3097,Co.C.) 505 - FINAL ELECTRICAL
m p Lenders Name
Lenders Addrtss 506 - GAS TEST
,a7 Z
J p I certify Out 1 have read this application and We that the above information is 507 - FINAL PLUMBING
W P correct.Iagree In comply with all city and county Ordinances andsateluwsrcJune,to
0 building coniquieinn,and hereby authorize mpecatntatives of this city mentcutdam the
5 FINAL MECHANICAL
Wabove-mentioned property for inspection purposes. O9 FIN E
(We)agree m save,indemnify and keep harmleu the City of Cupertino against
F h liabilities,judgments.costs and expenses which may in any way accrue against said
City tj FI (�
V z APPLIICCAcNTeof fine granting of UNDERSTANDS ArND WILL COMPLY WITIl ALL NON-POINT Issued by5s permit. 1 WORKS Date
SOURCE REGULATIONS.
Re-roofs 6r�03 - OF BATTENS
Signamrc of ApplicaH ZARDOUS MATERIALS DISCLOSURE Da1C Type of K0f4 - ROOF IN-PROGRESS
Will the applicant r future building occupant store or handle Imminent material
a defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safely
,Je.scones 2ssffi(a)7 All roofs shall be inspected prior to an roofing material being Installed.
❑vet ONO P P Y g g
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
mi t hazardous air conmminunts at defined by the Bay Area Air coal ity Management all new materials for inspection.
lutenist?
❑Yes 0 N
1 have read the hvarmms materials requiremenks under Chapter fi 95 of the Califor-
his Health&Safety Cale,S¢doa 25505,25533 and 25534.1 undersand that ifthe building
does not currently have a tenom,that it is my responsibility to notify the Occupant of the
requirements which mal be ren prior to issuance of a Cenificam of Occupancy. Signature Of Applicant Date
Owner or awhOri/Cd agent Date All roof coverings to be Class °Br Or better