02090099 . .CITY-OF CUPERTINO -- -
eun.omc DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: . - PERMIT NO.
19.6,24 ,'HOMESTEAD RD GOOD SAMARITAN UNITED METH DIS02090099
q - APPLICATIONUB DATE
AMAR,IT'AN•,UNITED -METHODI 09/17/2002
.PNONEa`Y• p:r'!•}:,�: .vt.+:n, ,,- .:.'i :",,. ,is
SANITARY•NO. CONTROL NO.
q 0 z0 ^'ARCHITECf/ENGINEER: 4 BUILDING PERMIT INFO
Lk" BLDG ELECT PLUMB MECH
v=mi i ,y' �i LICENSED CONTRACTOR'S DECLARATION Job Description
of q ,.« In ,by " ItIt
atlamliccnud d p naofcnapmr9¢ommwd^a' REPLACE CHILD PLAY GROUND
F C W; wdh S I n]000)o(D"s n 3 f the❑ .I d Pr fessivns Cade,and my bccnu
<3 is to full force d eff t !r.
�dza Lice uCla.
Door
Commnor 11 917 -
- 'i@ p `Y, `ARCI{ITECPS DECLARATION' '
�tl-�g -..% 1 undemend my plans shell be used as public rtcoNs
kpo o I icensea Professional OCT 2,is 2002
W �' yr OWNER BUILDER DECLARATION
WWWW 1 hereby affirm that 1 am exempt from the Contractors License Law for the,
t Q 'Okov g (Section 703 PS Business and Professions Cod Any 'ry or county - �' $20000
S C wh ch requires a Permit t construct,alter,improve demolish, repair any structure _ _- -_ .- _ LD g -
3$._pnot k uaksn req Neapplicam forsach permit fl sigradsatet Lig
a IhetkhRnidp atdN ma afonaarNacanvaursu m a Icnpx9' 1$1030 9or FF g q i ` Valuation
" ,fc m„vlcmgwilhS tot]ODIU (Dinvon3of Ne�u)ines antl Profs eons Cade)' COM-3 ,1.x:A. J,YE / 1l ..hi'€1 i',YI`
or Nolte"'d6olpt Ncrefrom'end the basis.for the alleged axempaau.Any vtolmlon `
of Section 4031,3 by any epplicaAoRira Penniuuhjens the applicam ro e civ1,penalty- ,,I
roma,moretnan:fvenundreddal7onasRf), 10jAPNP'®�DATION Occupancy Type
❑1;_._asrof the property.yr my employees with wage as their sok compcmmion. 102 PIER
• -1wal;ao'Ne work.-ene'N<'amcturc'is nor imm�eedror oHercd tar-sale(sec:7W;- ],O3 - UFER Required Inspections-'"
I Business andProfcssions Code:The Commnor's Liccnx law d«:not apply m en q p
owner oP n Who builds or im roves Nereoq and who tloes such work himself
2 of Ihroueeh
lin
yn atop!yeas Pro sed tont b p o emenk an oat Imeaded cr 104 - REBAR ,
'oRercd f s Id"If h e<r the hmlJ n Iii sold w'Nm ori of --'--- ' -_-._ -
105' - ANCHOR `BOLTS �:+.,., .:. .•,, , •,.':c
"complet oe the owner buddei w 11 have Ihc huNen of pries ng Nut he d d not bu Id ur 1• "
improve far puryvx atxk.). 106 SEWER '& WATER
WI..cit rust&._.._. --.. ---- -- - --' -- -- - - 202-=`-UNDERFLOOR-PLUMBING __ocilor; ^s n4 •.j+cons = _.._._..—
W Les,ow pmpcny,am exclusively comractinB wiN licenxdconuxtmam
t1a 7toa Business and Proteaons CodeIThe Convenors 203 - UNDERFLOOR MECHANI CALEI"f - "B
d Ito comrnns m apply t owner m property who Wilds improves I.m.do, 'tF )
ml t and(r such pm)ccta ww n contmctor(0 b nssed.pursuem m the_ _ 2 04---
Lacey'
ce t' d not
r, o nor Lc ;Law) BbP tanmsnapn 205 - UNDERFLOORS'-INSUTliATION
_� -`� 301 - ROUGH PLUMBING
o S ION DECLARATI 302 - TUB & OR SHOWER
yii maiineeprneuyof.p:i�ry;ogeo(m-mnowmgdecmratmns: 303 - ROUGH MECHANICAL'
wIII meiiririn'a'Cen1p6'Ic of Cnnieni'm xi...c for worker's 304 - ROUGH ELECTRICAL
C - pensgtinn, as provided•for by Sectio 3700,of 'he Labor Code. W, the
�( perfommnce of thework for which Out permit sissued..
IN305 - FRAME
,l 11lh Id IlinStnminWoke sCo" pen [o l ronce airce4undbySecvon 306 - HOEDOWNS -
`37M f,h landeCcite e to perfn f the work f n h"lib,Pemnt i. 3 0 7 - INSULATION
'Issued Myw h .. a I o I su_m pm Tess P II Y.n mbe art: 3.0 8 " S'HEETROCK '—' -- -I-
N —'
'.comer' 4rg Ih S le !t u4�a! r - "':, I � I ' .41v,. r 9 :I 1 tE ,.{ � t
-, Ilhfl EkTIPICAT1pNOI'CXTMPfIONFRUM,WORKERS ""' 309. I . s XTElfSORirLATH
CQMPFNSA'r1ON INSURANCE( h _
k ---_.--310-_ .
rrl xnidn'neeu,mbe=ampinaonepermter anehunJutlJuIFrs 311 `- SCRATCH COAT
-
{sloo) n...I
rm Ia -
'om I c' Ly- t'n N r'1, Of rk f r t h Rus perm t Ii i.ked I 501 F � D a
600nle I anyP nn gnkr a b,ePtohew,ke 503 - FINAL MECCTRICAL''tENERGY .
FINAL EIDE
C Iawa II I - _ 502.._ .. .FINAL?,P,LUMBING.. ENERGY_.
- — _ ..., .
IzN T PLI I f ePlateofExem Ito y usho W' HANICAL"•'ENERGY
be <sub)ea to t' Wrkers Ctimperst np isons of the Labor Code you muni
(onH
,in
comply Ih s ch Pro kions or this permit hal
W deems reked 504 - FINAL BUILDING ENERGY
�.'' '+a'�OhSTRUCr10N LENDING AOENCY 505 - FINAL ELECTRICAL
"' keno woo dog pg cyf the perfb 506 - GAS TEST
-FINAL'-PLUMBING
..r.. ..:_...._.._.-:... ......__
1 hercb aR'im Nm mere
of thew kf mch Nis perms
a a " - 50'7' "FINAL PLUMBING .
V.z. Lendc AJtlr s'^5 ni`!:
p � r 50 FINAL MECHANICAL
�•a I c a fy that I h re d td,.appltcauon and smm N nhe abo a of r, o Is ( g
Is F leo t I gree m comply nh ell<ay and c my b c s and tam la s rcl t g 5 9 - L
NAL G E' ' t Pon 5 0 - NAL NGlaagst 51 - NAL RKS
F, VJ linh I t egmcme cost J pence h h m y n any y egos t ad
C.7 � ry t cq en& F the� t'g of thI p mmt '
,T tCANT UNOERSTfkuDS Nb iVIf,L CONpLY'w)ITN ALL O4�POhY1"
Issued by; Date
Sig at rc f !Jca ftdmscs • : "'L 1 . • - Re-roofs
; , ., 2HAZARDOUS MATERIALS DISCLOSURE .
II t ppbcont a future Wilding occupant smrc or handl n
fv° ms om.t..I.. t a-AIsys eiot f Rsxod,o6,f15
S3-
a`tlefn d by he Cuperr Municipal Code Chapter9.12, ad Ne Heald,and Saf ry' 12-n1.,Cll
.touiiy roofingtnaterial.being insta.
l.led._ _ll roofsshallbe inspected prior ,.,,...
--_
re .. -
,,q51 mepPphca earm7prt maafng«wpanluxequipment ardevmwwM=h If a roof is installed'widiout first obtaining an inspection tltagre'e to`semove
con hawrilo -e Imiwnu ssdfned by the Bay Arte Air Quality Management'.
D st m❑Yea. , „ �a ,. all new materials for inspection Applicant understands and will comply with.
( ?"-`, - ( all non-point SOtlrcetegulahOnS,. i .• ,k.'.`:..; t . .•, _.-_-
.'+ 9s1 have rwdthe h zardous malenms rtquiu mente�under Chager 6.93 0!the
.9 ,CaLfomd Heahh'sn I Ity. all swc[a 25LI Iitis yrespoJ4bilito rnandthm'
bgilJiny tlMs nm purrcmly heveuknan4 Nat it is my reipo,lsitiiliry'to notify lh< •i,.,. ----
•,a t bF Ne III
i i winch-,must 'm t p r m is ce oC' Cenifcam or
nc u!
Signature of Applicant. __..__- . __-_ .. _._..Date,
L
.n.
Owner aI tl Dore em 1`. ` i' to gyp.,, All TOOT coverings t0 be Class"$"O,r belLal r
-----. ..OFFICE _._ ..
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