02090040 (4) Y OF
OI BL1L NG DIVISION PERM CONTRACTOR INFORMAI
BUILDING ADDRESS: PERMIT NO.
10112 SENATE WY nON 020900TE40
UB
`KMKA`?8 L SHT I NER APPuc 09 06/2002
A
PHONE: SANITARY NO. CONTROL NO.
q ZO ARCHTfEC(ENGINEER: BUILDING PERMrr INFO
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BLDG ELECT PLUMB MECH
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Z S v=Ni i LICENSED CON[RACnder provisions DECLARATION Job Description
of o Ihoreby mrmmatlam n3ofineBusinessAdaimsCda,andof Chapter 9 mmendng BATHROOM REMODEL
w is in Senlon]01Ib)of Division Jof the Business and Professiom Code,end my license
is in r.11:;t!tCd e �� FINALE®
Ac Por 6 V Use. Class Lic.N
Date Contractor
used u.u ARCHITECTS DECLARATION
°' ,g 1 understand my plans shall W used As public rmmds DEC 0 9 2002
i
25 0 O O Licensed Professional OWNER-BUILDER DECLARATION
I hereby affmr Nat I un exempt from the Conoactors License law for thc
C �U M�
r a following recon.(Section]031.5,Business ad Proressiom w Code:Any city county
{$ O which reel a permit to construct,alter,improve,demolish,or repair any structure
t�sam
3prior to its issuance,also requires she applicant for such permit toile o signed statement- - - - - - - - -
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talhdiSJicensedpursuSntjotheymvisiomof McConunctoesLicense Law(Chapter 9 �., ., .r 32%453tOF11!2PTQ. rA . • t•�-," Valuations
(commencing wit Saciion7000 d Pm
of Division 3 or the Both. Code)
or tat he it exempt therefrom and the basis for Me alleged aemption.Any violation
of Scotian 90313 by Any applic ih for A permit subjects the applicant to A civil pemlty A2N Occu ane T e
.of not more than five hundred doh,ars(SSW). 101 D ATION P Y YP
.4 DI,As owner of the progeny or my employees with wages As their sale compensation, 102 - PIERS
-will ea Me work,and to structure Is not intended or offered for sale(see:]a4; 103 — UFER Required Inspections
r Business ad Professions Code:The Contractor's License law does not applyrs such
an q p
owner of property Who Wilds or improves Overman,and who dors weak himself 104 — REBAR
or tnrour�ir his own employees.provided that such improvements are nor intended or _ _ ... .. ........ __-- -.---.----.._
-offered Po'r sale.If,however,the building or'improvement is sold within one year of - . . . . l Ob - ANCHOR._BOliTS....... .. 't,
compleron,the owner-builder will have the burden of proving that W did nor Wild or 10 6 — SEWER & WATER
improve for purpose of sale.).
_....-- - - .._..... ... ... .- ..._...-202 UNDERFLOOR--PLUMB -.
_ D 1,As owner d to m property.Aexclusively contracting with licensed contractors no
comwet be project(sec.]Oat.Business and Pmfessions Cad=:)The Contractors 203 — UNDERFLOOR MECHANICAL :, •..• •.
License law does not apply to an owner of property who Wilds or improves Marton,
„ '. .-ad.whorontmcufor such.projects.with.a.mantactur(s)licensed pursuantto.she _ .... .2.04. .-.-UNDERFLOOR -FRAME- ..._.._._._ _.,.._...._ ._,.._..._._....._.._
Contractors u=ende See. ,. 205 - UNDERFLOOR'l-.INSULATION
• f D 1 atrlesempt under Sec: - ;B&P C for this rtamn 301 - ROUGH PLUMBING
)' Owner Date
WORKER'S COMPENSATION DECLARATION 302 - TUB & OR SHOWER
Iherebyaffirm under Penalty ofpcdory,oneof,Mefollowing dedstarions: 303 — ROUGH MECHANICAL
-f D 1 have and will tninuin'A Crnificdu of Consent ro self-imum for Worker's 304 - ROUGH ELECTRICAL
Compensation. As provided for by section 37M of Me Inbar coke. far d,n 3 O5 — FRAME
performance of the work for which this pe(mir is issued... .
lhaveAndwillmamminWorker'seonipeoioeoolmunnd,a:Aeyoirdbrs«tion 306 — HOEDOWNS
r"37Ou or to W Wr Code,for Me,pcffomwce of the work for which Nis pemdf is 307 - INSULATION
Ca of y wt ha, Compenvtl=n Insurance tamer d Policy number Arc
,. _ 308 .-,-SHEETROCK..-.- _
51. x of ''PolicYNn.:' 7 349 oZ r
'CERTIFICATION OF.EXEMPTION FROM W,ORKERS' t 309. .'BXTEFZIOR:r L'ATH'„
... - COMPENSATION INSURANCE _ ...... . ....3.10...._.. INTERIOR"..LATH.. ..___.._.. .__... ....__ _....
"(This`LeLion need not be campleted if thc permit is for one hundred dollam 311 - SCRATCH COAT '
(slaolor less.) ..:313 - ROOF- NAIL.. -
112cr ify t i in the perfmmance of the work for which this permit is ismdi I 501 — FINAL ELECTRICAL' 'ENERGY
shall not employ any perm.in any manner mus to became subject ro the Worked
Comitant. aLawsofcafmmia.Da=Appl502 - FINAL -PLUMBING. ENERGY_.
NOTICE TO APPLICANT:If,after making this Cendfwtoc of Exemption;you should 503 — FINAL MECHANICAL'' ENERGY
become subject As the Workefs Compensation provisions of the Labor Code.you must
0fonbwithcomplywithmenprovismneorpermit hanWdeemdevoked.
this 504 - FINAL BUILDING ENERGY
• CONSTRUCTIONLENDINQ'AGENCY, ' 505 — FINAL ELECTRICAL
1 hertbY affirm tat do 'is a'construction lending Agency for Me performance
a > re . 506 - GAS TEST
r of n e work for whim this permins issue(Sec.309].Civ.C.I
y q -<eersName _ 507 ' - FINAL- PLUMBING
..7 Z Lendcr's Addmss •'s
50 FINAL MECHANICAL
1 cenif,Ma 1 have read this o lication and stare thm tW above information is
Tae'O Wilding
1 agree m comply wiser all city And county ordinances ed state law er upon
5 9 — INA
GRADE
O U th W,,c-coni.Aodor.Andhcxbyamnorizererome,. ivesofthiscirymcnmrupo° 5 0 - INAL NG
W the above-mentioned propcniy, and la Phar s. _ ,.
��ss a. (we)agree rosave,indemnifyad AeepnArmentne car or cAp<niroagainn 5 — INAL B RKS
Ps-(U!s liabilities,judgments.coos era espe.xs which may in any way accrue against said 4
U Z City inconsequence of the grunting D this permit.PI�}CCd?T UNDE ST NDSANOWtI COMPLYWT'THALLNONPOM Issued b Da�c5r
� r _SpGHCE REGIA 0.' Y<
�`Signature of ApplicanUconuacmr Dote Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Wei the Applicant orfumre Wilding oceupmt store or hedle tura d maedtl .. Type of Roof....,As der, by the Cupertino Municipal Code.Chapter 9.12,and the Heat And Safety
Coke.Section 25L12PR; . . ,: :'.,
❑Yes All roofs.shall be,inspected poor to any roofbng.material.being installed...._. ......_
Will the upplicantorfuture Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspeetiori;I agree to remove
,.it hazardous air conmmiranu m defined by the Bay Area Air Quality Management
District? all new materials for inspection.,Applicant understands and will comply with
DYa o No - all non-point source regulations::. . , . .
I have read the hazardous materials mr ttimments under Chapter 6.95 of he
CAlifurria Health&Safety Code,Sections 25505.25533 and 25534,1 undcrsund in.,
if the building does not currently have a tenant.that it is my responsibility to notify Me
o
ccupary=y of Me rcquint.m.which most be met prior m issumee of A Certificate Tbf
a`" Signature of Applicant
U� ow o aumori:<at a- .. Data All roof coverings to be Class"B" or better
.. .. ... .. ... . ... . . t.. , OFFICE. ...- .. ...
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