02090040 cl BUoF GDIVISION
BUILDING
PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT N0.
10112 SENATE WY 02090040
UB
OW"PELSHTINER APPLICATION
0 9/0 6A/2 0 0 2
'HONE: SANITARY NO. CONTROL NO.
O O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
to
baa
LICENSED CONTRACTOR'S DECLARATION
C S=0 1 hereby of irm shod I am licenced under provisions of Chapter 9(commencing Job Description
' with section 7fwo)of Division 3 ofine thim.ca:and Professions cwe.and my license BATHROOM REMODEL
ayy'V- is in full force and s. SSU
O i U Liccnse Class �- Lic.g '<-I 3
Doc Commc or
6 it a ARCHITECT'S DECLARATION
Nals I understand my plans shall be used as public records DEC 0 9 2002
yd O O Licensed Professional
Oat I am BUILDER DECLARATION BUILDING
ca-v, 1 rens shim that 1 1. exempt Good the Cession is Core:Any c Law for me
t 3'a followinguires a(session 9031.5, t.alias and Professions h,oAny city orcounty acture $14 0 0 0
E o which requires a pewit to conswa,ober,improve,demolish,or repair any structure
id � poor to its issuance.also requires the applicant for such Permit file a signed statement - - - -- -- - ------
a. that heislieensedpuisuhnlldtheprov,imonsof theContmaorsLicense Law(Chapter 9 �..< ' i Or].1QpF,Q a p q-- - Valuation
(commnic;ng with Sectlonl'1000)of Division 3 of the Baldnesrspmd Professions Codd 11.Ilv32a el5fit0 ),>'
or that he It exempt tAFimH m and the aids for the alleged exemption.Any violation
-of Station]03 L5 by any applicant fora pewit subjects sac applicant to.cmi pe alty-
IarwtmartmanBvehunareaaonarsu500A10JAENI� DATION Occupancy Type
❑I,azowmer ardrc propcnr.arm''r emplarea w;m a.,gasasma;r.olecampca.atian. 102 - PIERS
will-do the work:'And'the,tato is An,intended'tor bReted for sale(Secnam: 10 3 - UFER r r
(Business and Peofecsions Cede:The Contractor's License Law docs not apply to an Required Inspections''
owner of property Who Wilds ar improves mcrtr.,an0 who soots such mark himself 104 - REBAR
or through.his own employees.provided that such improvements are not intended or „_ ._ ---------
-;olleredForsblL:If.hswevc, he building or improvementBsold within one yearof -.- 10.5'...-`-ANCHOR _.. ..
---'-. '---
u
completion,mrov ,o owner-Wlmer will have the burden of proving that he die not Wild or
improve Tar paipoxe mrxale.). 106 - SEWER & WATER
------------.__ .._......_ -- - --..-- -202-=UNDERFLOOR--PLUMBING"--- ,,;
_..__..._
O I,m owner of the property.am exclusively cumnmroto
with licensed coctois
- -
n onswbt the proi<et(See.nus.Business and Professions Codec w
The Contractor 2 03 - UNDERFLOOR MECHANICAL '' is .
License Low.does but Apply toast ownerofpcond who Wild,icemimpmva r-tian
'. : r. ...ana.wna eantranra odes rash.proieets.witn.aeamra<taaal.ranaed par,aam.m.me_ . _. ._.._204UNDERFLOOR--FRAME- -.._._.-.___...
Commerce,License Low. „r„• ...
O l amiesempt under sec " s :BAPCfonM1is mason 205 - UNDERFLOOR•,:INSUI;ATION
301 ROUGH PLUMBING
1�., WOR D _
mer -
WORKER'S COMPENSATION DECLARATION 302 - TUB ,Sc OR SHOWER
Iherebyafirmanarpagahy or rervry,ome ar me rauawing ae<Iamtiona: 303 - ROUGH MECHANICAL
=F•0 1 nage aad will maihtai .'Ction6tdd Curacao m' lr-soda rot workers 304 - ROUGH ELECTRICAL
Compenmtian. as provided for by secaon PIX) of he La W, Code. far he
305 - FRAME
- - performance of the work for which mise permitsssaed,..,
1 have and will maintain Worker's Con,eAwtion Insurance,as required by Section X311
- HOEDOWNS
XW ohms IaWr cote.Tor me pekawamee ar me-work rarwlden mice permit e 3 0 7 - INSULATION
rued�MyW�Workers Compc satidn Insurance tamer dPolicyn�umeber arc 308 ?,-SHEETROCK -
cimar7t'rA7 1'agraecrNa: 7377— OZ i t';`"• '..309: '.-;:SXTEkIOR'LIATH';. •, ^I
t CERTIFICATION OF,E%EMPfIOY FROM WORKERS': n
t . 310.-,__ INT-ER'I OR"-LATH... .._...
1'Di s.caa nn odea oat be competed if me permit is for one hundred dollars 311 1 — ' SCRATCH COAT �. ,r'� i . '
3.13 ROOF- NAIL..
1 3enify that in Oe erforinance oftho work r which this permit is issued )
tshallnt employ any pe. in any manner.so as to become b3 tbme Workers! 501 - FINAL EliECTRICAL`'�ENERGY '
Camp ,. i nLn xatcrr A.Date 502 ..-._FINAL .PLUMBING. .ENERGY..
CmrA,dcant. -_ .. .. ....._.._
NOTICE TO APPLICANT If.after m kingm Connorte,ce ofE pto rouyoihould 503 - FINAL MECHANICAL' ENERGY
neco rte subjca to the Workers Compenmt p axons ofsfi lab Cxl.' u tams
O fisted imcanoplywitheach......too.,orhispewitshellbedeemedrevoked. 504 - FINAL BUILDING ENERGY
Z -
r corlsTRucnory�ENUlr+c ncENcv ' 505 - FINAL-ELECTRICAL
a Lender Add yss R vg Y fo the perfowance 506 - GAS TEST
rc
"t 1 hertb -R that S constructionIN 'lending-v C 1
�y - -[ends Name _ 507 FINAL MECHANICAL
oflhwork f nth th t issued (191C
o Z - I CAI; '
U O 1 st fy th s l ha e rc d du application d.i s that th W e of rmation is 5 9 - I NAL GRADE
cow t 1 8 to comply lM1 Il, wry and county ordinances and state I raising
OU toWilding wt ionnda byuthorte preertesfd city to ter upon 5 0 - INAL N NG
',} (Ar the abs a me t ed pri f inspection purposes, .._
. �_ Q. (N ) gee<tos0 a nce 'fyadkcephaml: thaCtytfCpen oagan.t 5 - INAL B RKS
U-(n Imbil,fiespdgmenls,costs and expenses which rosy m any way ame against said
UZ, City inconsequence of she emniin8 of permit... ' cga
ti PI AN UNDE 5'1' NIJS AND COMPLY WITH ALL 60N-POIM1T ISSI1Cd 1J Didte
CE REGU A 0' to /x_�_U'Z y<
Signature of ApIdicanosContraaor .' Date, Re-roco
HAZARDOUS MATERIALS.DISCLOSURE.
Will the a 6licw t future Wilding- p t t ,r n ndle na,ard- momnul Type
adef d by t-he Cupertino-M c palCale Chapter 9.12.and theHealth and Safety s ' r♦ � h s .1
i
Code,
od s Ii2{53201 s , 1 ' AK I{ S0r
'
-
All roofs.shall be.mspected prior to any roofing,material being.installed. ._.. ..
whin applicant rent future building occupant equipment devices which If a roof is installed without first obtaining an'inspection;1'agre remove
emit hatiorrmcs air cm Want.as defned by the By Are.A' Q lty Management
❑re ❑N. , . . - all non-point sourceregua[rons , PP I • stands and will,comply.with _
Diet t all new materials for inspection. A licant,under
: 1 have read he hazardous mvtenaH rtquirtmenss under Chapter 695 of the
Colirumia Health&Safcty Code.Sections 25505,25533 and 25534.1 undemund that "
H the Wlldlvg Jas not mncntly have a moans.thin o r my responaiof a to micas the
r
' ccupa9t of thinrequirements 6nrss h t r m issmnec of a Cen(code of
r Oe Q<y
\ _ � �� _ _ Signature of Applicant
o �a'm area a� `a�t t D. All roof coverings to be Class"B" or better ' ' .
,..'
OFFICE..