02100193 (4) CITY OF CUPEWI'INo •' "' :^ `"'
BUILDING DIVISION PERMIT > CONPRACTOR INFORMATION <i
IlUlla) DRNALLIN COT B. K. DEVELOPMENT CORP .G PERMITNO2100193
I&n'sM,%mLDEVELOPMENT CORP . APPLICAT12 13M.2002
PHONE: SANITARY N0. CONTROL.NO.
ARCIIITECTIENGINCER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
w00 LICENSED CONTRACTOR'S DECLARATION
0W P 1 hereby affirm that l am licensed under provisions of Chapter 9(commencingDg�rl r!`�1
0w with SeChun7NIO)of Division 3 of Ne Business and Professions Code,and my license EV�IS�aION (SIDI 1V "�"CCO�
�„ infullRmmeaedeffect. IN USE ONLY, NO NEW PERMIT ISSUED
Z Liecnsc Class Lin.M ORIG. #01100131
o Z F o Dale Lic.#Contractor
ARCHITECTS DECLARATION
W:;i I understand my plans shall be deed as public records
orFLL�� Licensed Prnressinwl
S OWNER-BUILDER DECLARATION
rc <q I hereby infirm that 1 for exempt from the Comourm's License Law for the
i p o following reason.Section]1131.5.Business and Professions Cute:Any city or county \\
X m� which leyuires a .it u)wmoni alley,improve,demolish.or repair any nracture
E�Ei< prior o its issuance.also ntquircs the applicant for such pclmiuo Glc a signedmintrcnl
that he is licensed pursuant to the provisions of the Coommon's Lice me law(Chapter 9 Sq. Fl. Floor Area 3139116 ition
(cummencing wi m Section700rhof Division 3 of the Business and Prolnssl^m@rkdon
y $ that he is exempt merchant and Ne basis for the alleged exemption.Any violation of
Section'/191.5 by any applicant for a permit subjects the 4PPI icant In a civil penally of :3 In driAbela'U
not mac than Five hundred dollars($5D]). Occupancy Type
0 I,m owner of the property,of my employees with wages as thelf sole ccup,maation,
will do the work,and the sumeaa is not intended or offered for sale(gee.]M4.Buainess
and Professions Code:The Contractors License Law does nm apply lac an owner of 102 - P I ERS equired Inspections
property who builds nr improv.,thereon,and whodocs such work himself orthrough his
own employees.provided that such improvements arc not intended uroRered forsale.If. 10.3 — UFER
however.the building or improvement is sold within one year of completion,the owner 104 — REBAR
Wilder will have the burden of proving Nat M did not Mild or improve for purpose of
sale 105 - ANCHOR BOLTS
0 1,m owner of the property,am exclusively contracting with licensed contractors to 106 - SEWER '& WATER
consumer me project(Sec.7844,Businessand Professions Code:)TM Contractors Li-
cerise Law does not apply to an Owner of property who Wilds or improws themon,and, 202 - UNDERFLOOR PLUMBING
Who conuacu for such pn)kCU with a comnnor(s)licensed pursuant to lM Convectors
License Law. 203 - UNDERFLOOR MECHANICAL
0 l am exempt under Sec. .B A,P C for this reason 204 — UNDERFLOOR FRAME
One, Data 205 — UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION 301 - ROUGH PLUMBING
I hereby aBilm under penalty of perjury one of the following declaremions: 302 — TUB & OR SHOWER
C l bvmand will maintain.CeniGeme of Conum m sel6imm.for Workch Cnmpem 3O3 — ROUGH MECHANICAL
cation,as provided for by Section 3]110 of the Lather Code,far the pem mm cc of the
work for which this permit is issued. 304 - ROUGH ELECTRICAL
0 1 have and will maintain Worker's Compensation Insurance,a required by Section 3 05 - FRAME
3100 of the Labor Code,for the performance of IM work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am: 306 — HOLDOWNS
Came= Policy No.: 307 - INSULATION
CERTIFICATE 01'EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 308 - SHEETROCK
This section need^.,McomplemM p
d iflermit is formic hundred dollms($100) 309 - EXTERIOR LATH
erleaa.) 310 - INTERIOR LATH
I ceniry mal In the PeThumance of the work for which this permit Is issued,I shall not 311 - SCRATCH COAT
employ any Mrmm in any manner sn m m become subjen m to Workers'Compensation
Laws of California.Date 313 - ROOF NAIL
Applicant
NOTICE TO APPLICANT.IJ,after making this Cenificam of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become subject In the Worker's Compensation pavivions of the l.ahor Code,you must 502 - FINAL PLUMBING ENERGY
O O forthwith comply with such provisions or this permit shall a deemed revoked.
z CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
h agency
kIhichtmmmmereissuenarondnle^dinsasencrrermerrfmmanecer 504 — FINAL BUILDING ENERGY
a >
'he wnrklnrwhicAthisp mimisissucd(Sca31 ],Civ.C.) 505 - FINAL ELECTRICAL
lgl Q Lcndcr's NO
az Iande'aAddress 506 - GAS TEST
U O 1 certify mat 1 have read this application and sale that the above information is 507 - FINAL PLUMBING
v. F+ comet.I agree to comply with all city and county ordinances and state]aws rearm&to 5 FINAL MECHANIC_ AL
building contraction.and hereby audlerix repre,mmideas of this city to enter up,m me
lUi1 alcove-mentioned keeps. O9 FIN GRADE
(We)agree ro save,indemnify and keep harmless IM City of Cupertino against
F' y liabilities.judgements,costs and cxpcnua which may in eny way emmc egamsl and City
5 F N L G
U z in consequence new grading of thispermi 1.
^t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT Issued by 51 WORKS Date
SOURCE REGULATIONS. VPL""/
Re-roofs603 - OF BATTENS
Signature of ApplicaI(AZAR mor Dam
uAznRDOeBMATERIALS t,uncDISCLOSURE Type of l�m0f4 — ROOF IN—PROGRESS
Will dlc applicant nr future building e,Chapter
mere of huddle I rxdnudd Sena l
s defined by the Copeninn Municipal Code,Chapter Y.12.and IM IIcxlMand 541cty
de,recce 25532(ayr
O yes ONO 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
emit hazardous air contaminanum defined by toe Bay Arca Air Quality Management all new materials for inspection,
District?
❑Ycs ON.
1 haw real the Mmdrnsv mmerials icipikemenu under Chapurfi 95of me CaliRv-
.is licaldl6 Salty Code,Sectiem 2S505.25533 ant125534.1 turnaround!mal if the Milling
does nut currently have a tenant.mal i1 is my respOmlflility b)mm y the Occupant of the
requiro armswhichmas]Wme. ximmissuanaofaCertipcateorfkcupmmg Signature of Applicant Date
Owner of adborired agent Date All roof coverings to be Class "B" or better
I