03080130 (2) CITY OF CUPERTINO „d°- P "�+'-� - .*
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
OUILDING ADDRESS: GEORGE TU - PERMITNO03080130
40n SCENIC IRT-171)
R'S NAME: PERMIT ISSUE DATE
IS: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
i00 LICENSED CONTRACTOR'S DECLARA QN
IC 1 hereby efllrm that 1 am licensed under powmiuns of Chabscr 9(commencing Job Description
b wish Section]IXNq of Division Jof tete business arta Prufcuina�Code, dray liccve is
ifull fd n uorce aneffect. REVISION--INHOUSE USE ONLY
Lken>CClaxa Lie,g
Date-CarTSDECLARr
ARCHITECTS DECNO NEW PERMIT/ ORIG. #03080130
ATION
E 1 and cratand my plana shall be used as public¢cords
)KV
o� Licensed Professional
OWNER-BUILDER DECLARATION
<I 1 hereby affirm that I am exempt from de Contractors License Law for sw
O O following moon.(Section 7031.5,Business and Professions Code:Any city or county
$ which requires a Permit to construct,sitar,improve,demolish,nr repair any strucwm
7�T prior Aa its issuance.also requires the applicant for such Permit to rile a signed snamenl
m¢< Nat he is licensed punuanlw she pmviainosof Ne Com.Lm's License law(ChaP¢f9 Sq. Ft. Floor Area Valuation CO-
eF� (commencing with Section 7")of Division 3 of the Business and Professions Code)A,
Nat he is exempt thertfrom and the basis for the alleged emmpuon.Any violation of
Section 7D31.5 byarry applicant for a permit ubjects the applicant to A civil Penalty of 3 ly y grpp Occupancy Type
not more Nan live hundred della.($500).
❑h as owner of the property,or my employers with wags a'Nei,sok compensation,
will do The work,end tie SMAAM is not intended or offered for sale(Sec.7044,Business Re eCIIODS
Olred Ins
and Professions Code:The Condiment's Lice=Law docs not apply u an owner of 101 - FOUNDATM i ON p
property who builds or improves damon.and whodoes sub work himself or through his
own employees,provided Na Aide. 102 —such improvements Am not intended oroRemd for P RS
however.the building or improvement is mid within as year of completion,the owner-
builder will have Ne burden of proving Nal M did not wild of improve for purpose of 103 — OF
104 - REBA
❑1,as owner of ct property,.B exclusively Protrusions
with licensedcontractorsto
construct the project(Sec.7044,Boinw and Rofes'ions Cede:)The Contractor's Li. itis — ANCHO BOLTS.
ase Law does Act I.an owner or propcny who wilds or improv down..and 106 — SEWER & WATER
who contacts for such projects with a con=wr(s)licensed pursuant the Com actor s
L'enmLaw. 202 - UNDERFLO PLUMBING
Ism exempt under Sec. ,B&P C for old...no 203 - UNDERFLOO MECHANICAL
° 204 - UNDERFLOOR RAME
COMPENSATION DEC ION
he arm unser Penalty of perjury one of flue following declarations: 205 — UNDERFLOOR I SULATION
I hoc and will maintain a Cenifis¢of Consent to set Nasum for Workers Compcn. 301 — ROUGH PLUMBIN
Asian,As provided for by Section 37W of the Labor Code,for the performance of Nc 302 — TUB br OR SHOWE
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,u required by Section 303 - ROUGH MECHANI CAL
3700 of the Labor Coca,for she performance of Ne work for which Nis permit is issued. 304 — ROUGH ELECTRICAL
My Workers Compensation Insurance carrier and Policy number Am: 305 — FRAME
Cartier: PoliCERTIFICATE OF EXEMPTION FROM WORKERS' 306 — HOLDOWNS
COMPENSATION INSURANCE 307 INSULATION
(Thu section need notes cwnplead if lbe permit is for one hundred doilan,n IMO 308 - SHEETROCK
m IcvJ
I cattily Nat in Nc perfsemanea or the work for which Nis permit is issued.I still not 309 - EXTERIOR LATH
employ any peon in any manner so n w become subject to the WorkeKCompensation 310 — INTERIOR LATH
Law'alCahrOmia.Doe 311 - SCRATCH COAT
Applicant
NOTICE TO APPLICANT:IL after making Nis Cemfmate of Exemption,you shouW 313 - ROOF NAIL
become subject to the Worker''Compensation provisions of tw labor Code,you most
.JZ fonhwuh Comply with such provisions or this Permit Mail Ito deemed invoked. 501 — FINAL ELECTRICAL ENERGY
? M CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
F+ ... Ihemhyaffirm tat then is.construction lending agency for the performanceof 503 - FINAL MECHANICAL ENERGY
!Yi the work for which this permit Is issued(See.3W7,Civ.C.)
m A
Lena 504 - FINAL BUILDING ENERGY
= z LcnaersAdd ss 505 - FINAL ELECTRICAL
U0 I sentry that I have mad this application and Atoa that the awes information is 5 0 6 - GAS TEST
cored I agree to comply with all cityand county ordinances and sum laws relating to
O(J building construction.and hereby authorim represenmiwa of this city to enter upon theFIN PLUMB G
r G ahovo-meminncd property ferimPcctinn purposes. IF
(We)agree w save,indemnify and keep Arminian the City of Cupcnino against Q 8 F I L
.F".i CA Ilabllidcs,judgmcnts,casts and expenses which may in anyway accrue against said City 5
t.)z in cooequencc of the granting of this Permit.
^ APPLICANT UNDERSTANDS N WILL COMPL WITH ALL NON-POINT Issued by: ING Date
SOURCE REGUL N _
—�^ Re-roofs 4 NAL PUBLIC WORKS
S aur .tractor w
A2ARDOUS MATERIALS DISCLOS Type of Roof
Will capplicam ter future building occoP21i Ara havamuu'mawdsi
aerned by the Cupertino Municipal Code.claim,9.12,and the Hshh and Safety
.Section 25532ca)+ A All roofs shall be inspected prior to any roofing material being installed.
Will Nc applicant r fuwr building occupant sew equipment or acvicc'which If a roof is installed without first obtaining an inspection,I agree to remove
it haramous airconmmin U dcfncdby NCBay Aar Air Quality Management all new materials for inspection.
iarieR
❑Yes
I have mail the ham ousmateriau requirements under Chapar G95 Attie Califor.
niallealN&Safety Cudc,SCNons25505,25533 an125534.I understood that iritic wilding
dins not camenuy we m 4 Nat it is my reaponsihility to Ann[be mxupant of the
requirements h rmissumccofaCcrufcamofOc91phan . Signature of Applicant Date
Vl.m
m sent Dam All roof coverings to be Class "B" or better