01050065 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PLRMnNO.
10140 LOCKWOOD DR 01050065
OWNER'S NAME: APPLICATION SUB DATE:
TED AND DIANE COHN 05/07/2001
PHONE: SANITARY NO. CONTROL NO.
0 m Z ARCIIITF.CIIENGfN[LRo BUI I'LRMII'IN
µf100 BLDG F.LE PLUME MP.CII
�I I: IJ
FF N y
LICENSED, CON]RACTrdOR S„ , DECLAwi,imORATION Job Description
O Z C 1 hereby affirm Ohm am licensed B line Omvisiu1 of Chapter 9lcnmmenense
is in full game
a and of effect. unJ til the lhasincw and Prulexpvan,CnJu.:unl my license
<x mm�rareeaneeBee'' KITCHEN REMODEL
Lice:.,Clns. Lia.p
O Umc Comcmm!
shit;3 a n ARCIIb
II' e,T'S DECLARATION
1 undcrsmnJ my pl:uw.hull be nwJ n.public records
ceis n Liccmed 1'ndessinwl OWNER a� BUILDER DLCLARA'1'ION
ul I hereby aRiml Thar I am emmpy from the Contractor'%Liceme Law for the
Z a Ibllowing nnwn.sconon 703I.5.Bminess and Prnfeoions Code:Any city nr nmmy
7=0 which m,,Tims a peon;'bit"Invio n,alter,Improve.Jemoli h.ur mpair any structure
a°f�-9 prior to its issuance.also requires the applicant for suchpcomiun file a signed stamen'
o.-- not he is reveled amoLmtrohe,m..mns To llhe C:,mrar,<,rxueenxcLaw(Chapter 9 Sq. Ft. Floor Area Valuation
leomntencing with Section 7 010 of Division 3 of the lisdncss and Prol'ecsinns Code)
or Ihat he is exempt therefrom;rod the busts lir the alleged exemption.Any vfolalon $
of Section 7x31$by any uPPllcun tura ftertui'suhlec's the npplicntn m a ci.11 Iwnally
Of Out mnmban rise hundred dnna,as5au. APN Nonni - Occupancy Type
❑Lon owner9nhe nreperry Ormr eamleyees with wanesm thelrrolecompcnaarim,. 42 - 1
will do the work,and the arucmm is not intended or offered for sale(Sec.7044,
Bitureaa I I Povex.itme Ceae.:'Um Casts.......L henxa Law sues To apply'a as _ Required Inspections
r of property Who builds or improves thereon,and who does such work himself
son�aanh his Own employee..Provided that such improvements are nos intended ar 304 — ROUGH ELECTRICAL
uttered for sale.If.however in,building Or impewemmat is sold will'!a one year ul'
completion,the oner,builder will have me burdenm
o'pving that he did not build or 501 -- FINAL ELECTRICAL ENERGY
zI"pa`Pwa”°f"n"' 505 FINAL ELECTRICAL .
ser afmc property,am exclu.kdr contracting with hcemed contmamn to
moved the ptojec,(Svc.7044,Bushes,xnd pmIr,,iun.Codec)The Co m tor'.
License La Joe,not apply to an owner of property who build%or imm
proves Ibem.
and
who n... aerc far each projects with a cammetorls)licensed Pursuant to the
Cnntrnc'nr L ' law.
❑Ie. p' Soc .BR PCfo this n�u5s
Ox'n : 'S COMI'fN5ATl09 DLC1ARATlO �yl- FINALED
1 hereby affirm under penalty of perjury,one of the following declarations: -
MAY 2 9 2001.
p 1 have am) will maintain a Cenilicate cl Consent tit,Lail-inane Ibr Workers •
Compenummn, a, provided for by section 3710 of the Labor Code, for the
peJhnanaeeaf the wire Ila whish Ibis permit is issued.
❑1 have and will maintain W..ITT's Compensation Insurance,To required by Section BUILDING
3700 of the Lab...ode,I the pefllmnunce 0 the wild for which Wis permit is
ssued.My Workers Compensation Insurance carrier and Policy mmrder are:
Cartier: Policy No.: '
CERTIFICATION OI'EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE: _
(Thi,.,,lion need not be completed if the Pc.I,is for one hundred dollars
IS 100)or loss.)
I cenlfy'bar is the pnhrmm�,e oI'the work for which his Penni'is issued,1
shall not employ any person in any manner uh aC as hislan"Object to the Work"'
Compemmioo Lows of CWifnmiu.Dam '
Applicant
N0oCE'10 APPLICANT:If,after making this Cenittcalc of lixnnplion.You should
necOtae subject to the workers Compcneeion provisions of the Labor Code,you as,
Q 0 ranhwid,eoniply with oam mokiOm or this,omit shun b,Jea.tied to-1,0.
z^r ^ CON S'FRUCI'[ON LENDI NO AD ENCY
y, I hereby aflim,Thad here is a construction Icadi ng agency for the perlonnarae
of,he work far which this panni'is issued(Sec.3097.Civ.C.)
6. Q Lcadcr's Name
= z 1 cadcr's A,dress
U Q 1 comity that I hove read his applicmian and s'am'hht lhn above ink Talon is
sec'.1 agree m comply with all city and county ordinances and slate lawn relating
Q V cbuilding etntru„io
xn,soul herehy nuthoriaerepmen'a'ives of this city to niter upon
tuhe abO.e.me nioned limit for inpeent n purpose..,
rtra d (We)agree to save.indemnify and keep harmless the City of Cupertino against
m )mbirues.Inanition,..c9sts;tad cxlcnscs which may in pray way acerae agaia4 sale T
U Z City in consequence Of the granting Of this perm;,.
^ APPLICANT UNDERSTANDS AND WI LL COMPLY WITH ALL NON-POINT Issued by: t L Date
SOURCE RIA ULATIONS.
Slgnammotnpl,IiealnrCOalraCha Date Re-roofs
IIA/ARDOUS MATERIALS DISCLOSURE
Will the applicant or foutre building tu,np:m,'tote m handle heo Irdast malum Type of Roof
To defined by du Cape him,Mo uiaipal axle Chapter 9.12.it aI the Holill sad Side"
Code,Section 2553200?
oyes Cl No All roofs shall be inspected prior to any roofing material being installed.
Will the apphc:mtorfuture building Occupant nseequipment ordevices which If a roof is installed without first obtaining an inspection, I agree to remove
unit burarJoux Bir cnulatninuntsmacOnod by the Bey Area Nr Qnnlhy M1tanagctnent
�)s,,;c,7 all new materials for inspection. Applicant understands and will comply with
ores 0 N all non-point source regulations.
I base read me harardoO materials repair terns under Chapter 6.95 of,he
Cdifmm�t Heal'Ith 5l1111y Ceodo.Seen To 2550.5,25533 and 25534.1 und,rstand mat
film building docs not currently have a tenant.that it is my reslnnvihikly in na'ily lire
cup:no of the requirements which In ,he rte,prior m issuance of a Cenificute of
oce
ec ' `y. Signature of Applicant Date
Owaerer amhad,ad agent Dale All roof coverings to be Class "B" or better
OFFICE