06100041 CBUILDING DIVISION PERMIT ITY OF CUPERTINO
P1 �� I� Q�I�tE�}�M�TIa►N�'
nLDI PERMIT NO.
ANVICK SCOTT E AND JANET 06100041
i4 t; RQT T TN(,ER RE) PERMIT ISSUE DATE
rw NER'S NAME:
ANV I CK SCOTT R ANT)_JANET SANITARY N 06� L NO.
NE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION Job Description
iU I hereby affirm that I am licensed under provisions of Chapter 9(commencing
;z w with Section 70(X0)of Division 3 of the Business and Professions Code,and my license is
=y in full force and effect. -2VELUX OPERABLE SKYLIGHTS 2 X 3
? License Class Lic•#
t p Date Contractor
ARCHITECTS DECLARATION
C< 1 understand my plans shall be used as public records
ryU
to,E„ Licensed Professional
y
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
3 p Oyfollowing reason.(Section 703 1.5,Business and Professions Calc:Any city or county
which requires a permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ��,�y,,w.
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of IgWit . 0 0 Occupancy Type
not more than five hundred dollars(5500).
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If.
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law docs not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a cont actors)licensed pursuant to the Contractor's
•tse Law.
Lot exempt under Sec. ,B&P C for this reason
`Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
H►�+ I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C.)
W Q L.endcr's Name
az L.endees Address
U 0 1 certify that I have read this application and state that the above information is
LL►. correct.I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
C1. (We)agree to save,indemnify and keep harmless the City of Cupertino against
CA liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. Date
—+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATIONS.
Re-roofs
Signature of Applicant/Contractor Dam Type of Roof
HAZARDOUS MATERIALS DISCLOSURE yp
Will the applicant or future building occupant store or handle hazardous material
defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Calc,Section ea 25532(a)? ❑No All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
[3 Yes ❑No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a certificate of occupancy. Signature of Applicant Date
All roof coverings to be Class B or better
Owner or authorized agent Date
CITY OF CUPERTINOwa +i�P'sk'
BUILDING DIVISION PERMIT CONTRAMPR I1�FF0RMATIq�
BUILDING ADDRESS: PERMrp NO.
ANVICK SCOTT E AND JANET 06100041
WNERS,FAME PERNMLSSUEDATE
10
ONE SANITARY N L N0.
ARCHYECTfeNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB WCH
ZZ 0 (�
� TRACTOR'S DECLARATION Job Desert UOn
0 LICENSED CON
F 1 kmeby,Ilion that I w licensed under provision a m ,mer 9(commencing p
wth Section 7Uf10)ar Division 3 afthc Business and Professiau Code,and my toms is
13 mrWlroaawarrm VELUX OPERABLE SKYLIGHTS 2-2 X 3
Z Lens Cua Lie.Y
Dat Comramr s .
dJ` ARCHITECTS DECLARATION
I wdrmand my pima shall W used as public reeoNs
U
.00 Li¢,dsd Pmfewow
OWNER-BUILDER DECLARATION
I hereby alarm that 1 am eaempt from the Coaaactaf,LJeens law for the
ZOO following mood.(Section 7031.5,Business and Profcsaia s Coda:Any my or caaty,
2 K whuh wquaes a Permit to conarocl a1ur,hnpcom demolish,or repair any arvmum $j Ann
z_r prior bk,i9WnR.AM mQniraS the avdizaIIt rIX"eh Permit In file a signed aWelmlm
-
xx, Jwt he u nceacJ Pormom'to the PWvislam or da e
Cordr0ul IJens taw(Chapoer 9' Sq.Ft. Floor Area Valuation
[F (carmmmtan withSection 71100)of Division 3 or the Business and Pmrusiau Coull)car
$ dud W as eainpt rho opm nes and tie bash fu rite Cleild csempuon.My Mhdan of
Secdad 7031.5 by my appaca u for a permit subjenx Nc applicmt to a civil Pmulty of � �
190r. 0 Occupancy Type
rat more plum 0oe hWdmd dellvs(5500). .
D I,as..(ft propm,Y,or my,aoplrycas with cogs as Jew sole comiena,don,
will do Ju work,soul the souctute h not intended on ofrcmd fa sale(sec.7064,Bunions
ark Prorcvlmm code rbc Cmvemo ms w'-s Las ladm not apply to as ow.ar / Require ons
property who bunds a lmpmcs Charon,and whin dect.1i work himself.through his //� /
owo empb)¢s,pmrided thea suc4 impmwrocrus art inard
WL rd a offced(rink.IL `/O
boweva,me billing a impmoemcnt u sWd widun use y�of tanpledms,the-- 6
Wilda w ba.e the hdvdco of proNng that re did cot hmd or'uoprme fa impious W
sat_).
Q 1.as owner of the property,am esetuslvcy contracting wild Ii¢msrd mtuac.W
eorut.the proem(See.7046,Business sad Prof=.code:)The Coaowa L4 .
m law aces oro apply W an awrcr nd proP y who Wilds or improscs thcemi,and.
who contracts for such pmjbw wah a eaouaewr(a)Ilttmsed pursuant to We Comrnot,
Lice.raw.
❑Iuoaemptmccr See .BRPCfatans.
Dna
WORKERS COMPENSATION DCCLARATION .
I bcaby affirm unhr penalty of perjury ms of the following deelarsho. .
❑I N+e artl will murrain a Cud0ou W Cons,b slf-intone far Wakefs Cmnprn
sues,as Pa,widol ror by Sesuen 3700 a the labor Code,fm tie pmfonmuac W We .
work fm which this Permit u lmued
D 1 hon and will maintain Wcr tr a Cosnper d..Inwr .as nNuud by Scabs
r7(IO d de tabs'.. fa the palm cmisof the work fa which Nu pemdit u lvucd.
My Worter's Canfcnal®Ingaa,xz anis and Policy number ase:
Cartier: Policy No.:
CERTIFICATE OF ExEmpnoN FROM WORKERS'
COMPENSATION INSURANCE
(Thh scum need sla Wcornpai If the pc,mu u fa ane hmmed duras(SIO%
orku)
I unify Jut in the perfbran.of the wart for which Ni,panni,Is isstcd,l man nes
curt,any person in any manner so as m become subject b the Warkmi Caaportsadon
taws of Califurom Now
Applicant
NGmCE TO APPUCANP.If,alar making Nu Ccnlfkatc W EacmPtiM INN should
Wearr,ubjmh b Jur Wa .Caopcestion poorisi .of the labor Code,you mus
.J Z rardwith comply with such pro n,or this+Pamit"I W d¢mM rmakcd
Z O CONMUCrION LENDING AGENCY
Ibemhy orf that dere u a cona,vetkm lemoling agney for the Mifmmanco of
fyi 7, the wok far which dols permit h issued Sm,3097,Civ.C.)
W 0 Lender,Nomc
aZ 1<sdefs Adarras .
U O 1 an1fY that 1 how,had Chi,application,sd suw that the aW,u ur.tho,u
Irk. casco 1 agru to comply with 01 city and camty arJuu,cea and sure laws rtlaum,W
0 Widingcrosuucctoasdbcrcemnify ausccp himocla or Nucity wrntinoa iM
r a ahooe-mentioned pmPcrtY ter irm,ccoan purposes
(Wes)assce lo,aoe,indemnify and lisp hay in m the City lu Cupertino idl Ci,a
UZ ilabllivaludgm(na.eonsandoexpenses thisewhich may Inanyway acuuc aguatsakCty
U Z. inuilL
APPLICR AaN7 UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
51g"amrc of Applion� US MATERIALS DISCLOSURE Date of Roof
WOI the spplitant no fano hulling occupant gone or hands haaa,dmts at
As colored by Je Cupertino Municipal Coach Cbapwr 9.12,and the Health and Safety
Code,Scmbn 25532nd7 All roofs shall be inspected prior to any roofing material being installed.
Dyes, ON.
If a roof is installed without first obtaining an inspection,I agree to remove
Sin,he applicant or future bailing W,,,"as equipment or dm+roa which
emit hurudmu ser conumuunts as domed by Je Bay Ama Air QuantY Mamagmea all new materials for inspection.
Di,ukt7
❑Ya 0N
I home mad Je harudau materods notore.under Charym 6.95 of the Cannor-
rusH lh&SJoyCodc,Sections 25515.25533 md25534.1 untrnuul ILuileac huldog
Jam cot currenJY pus a acta,m dust It h my rc,poouhllity W nWry Je amupam or de
agaianenu wnknadaa be shat piabi,aa,r,roa,cudlr.earo<np.r>. Signature of Applicant Date
owner amf,i.d ag,r, Dat All roof coverings to be Class "B"or better
IRM
zzmg
1 +IDS ry P�R®JEC® R-SHtE'E>
CUPEIZ,TINO
Assessor's Parcel Number:
Name of owner. S�'r�T7 i� &Su IC
Project address. (0 0
Contact person. Phone. k CD — 3 LJ Y D J�
Fax.
Net square footage of lot.
Existin Proposed
Square footage: First floor:
Second floor:
Garage:
TOTAL:
• Are.there at least two 10 foot by 20 foot clear spaces inside the garage? O N
Is privacy protection planting required for the project? Y N
On what floor(s) is work being done? R r?P,-2 U 1 (IS tiJjn y W W-9)
APov ��
ef description o work. c� c V Q U k � '� }f ,IiI
�tiFRTIPI(t (`ODI' dun n - . ;'iiiiW
Code editions: 2001 CBC (Y - N)2001 CFC (Y -N)2001ATvI
2001 CPC (Y -N)2001 NEC (Y -N) >IGNEUC__��" �Itlons
_
'his set of plans and MUS7
,a kept on the job at all tlm_s -nd it is un
awful to make any changes oalteratlont
Effective 11/1/02 In same without written pe rn ssion iron.
Ile building Dept., City of C: , :;no,
he stamping of this plan an,. -p.,citicatiom
HALL NOT be held to permit ur to be ar
1proval of the violation of any prowslom
city Ordmance or $rate Law
Mpy OCT o 8 2.000
Plan Review Process Work Book Page-B-Revised 8/27J05
737
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