00080102 CITY OF CUPERTINO >sa2•saa.
BUILDING DIVISION PERMITaCONTRACTOR INFORMATION
BUILDING ADDRESS: KORNATI PROPERTIES PERMITNcb 0080102
22385 RANCHO DEEP CLI DR
OWNER'S NAME: PERMIT).SUE DATE
DEHART RENA F 19084 TILSO
ONE:
SANITARY NO. CONTROL NO.
(408) 996-2817
ARCHITECT/ENGINEER: BUILDING PERMIT INFO -
BLDG ELECT PLUMB MECH
u 00 LICENSED CONTRACTOR'S DECLARATION Job Description
e�� 1 thereby afrm that 1 am licensed under pmvisiou of Chapter 9(commencing
n Udo with sfome ndcffm Division 3afthe Business and Pmfessma Code,and my tic.is
>ta_ LipensClass Lk.a REMODEL-REPLACE TILE. INSTALL SHWR VALVES
Dam Contmcwr
ARCHITECTS DECLARATION
5y < 1 undersand my plans shall W used as public records
DyU
it G Licensed Professional / ^
OWNER-BUILDER DECLARATION .LJ� 1 /2, 3 0
I I hereby affirm Not 1 am exempt from the Contnctore License Law for the
i O O following Mason.(Section 7(51.5.Business and Professions Code:Any city or county
$ which roqulres a Permit to enmorant.altar,improve.demolish,nr repair my strocturo 811000
—zi priork,its i6aaMC.a1m,rec iRl LWAPPlicanl forsuch permltlo file aligned statement
i< mathearatasedphanmathtprowsionsofrWComrscmrsLiccuseeLaw(Chapmr9 Sq.Ft.Floor Area Valuation
x1- (commencing with Section 7000)of Division 3 ofthc Businessand ProfessionsCMe)m
Wt W is exempt ocrefrnm and the bass for the alleged eamption.Any violation of
Scale.7011.5 by airy applicant far a permit subjects the applkal In a civil penalty Of er0 0 Occupancy Type
not ream than five hundred doWrs(5500).
❑1,uownerofthe Property many employees with wagesuomr.emmpensation,
will do the work,and the structure is not intended or offered onak(Sec.7014,Boston.
sea profesomm;Code:The Cona.emrs Licerom,law rens not apply m an owner of Required Inspections
property who buildsa improves Cher an,and whodoessuchwork himselfor through his
own employers.provided matsuch improvements are not intended oroffered for sale.IL
however,the Wilding or improvement is sold within can you of oomplctlon.the owner.
builder will have the burden of proving Net he did not Wild or improve far purpose of
sak.).
❑L as owner of the propony.am emiusimly contracting with licensed contracmrs m
tru
consct the pmjcct(Sec.7014.Business and Professions Cadc:)The Common'sLi-
ccmc Law does not apply as an owner of progeny who Wilda or improves dammon.and
who contracts for such projects with a conontor(s)licensed pursuant m the eoneractoes
License Law.
1 am exempt under Sec. .B k P C for this rmwn
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby alRrm under pcalty of perjury ore of the following declarations:
I have and will maintain aCenifrcare of Consent to self-insum for WorkcrsCompen-
sation,as provided for by Section 1700 of the labor Code.for the Performance of the
work for which this permit is issued.
(]I have and will maintain Wortmes Compensation Inmrance,es notional by Section
37W of this labor Code,for IW performance of the work for which this Permit is issued.
My Worker's Compensation Insurance artier and Policy number are:
Carrier, Policy No,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not k completed If the Permit Is for one hundred dollars(SI W)
or less)
1 certify,Nat in the performance of this wells for which Nis Permit is issued.I shall not
employ any person in any manner so as m become subject to the Workcri Comper auon
Laws of California.Date
Applicant
NOTICE To APPLICANT:If.after making this Cenifiesm of EacrepWn,you should
become subject to the Worker's Compensation previsions of the Labor Code,you must
.,2 forthwith comply with such provisions or this Permit shall W rimmed revoked.
ZO CONSTRUCTION LENDING AGENCY
F+� Ihereby affirm that Nem is a eommucton lending agency for the performanac of
as7 the work for which this permit Is issued(Sce.3D97,Civ.C.)
aQ Lenders Name ,
DLenders Address
V 0 1 certify,that I have read Nis application and soon that the above information IS
F' coeccL 1 agree in comply with all city and county Ordinances and sum laws relating as
0 V building convection,and hereby authonee representatives of Nis city to polar upon the
�t17 aWvrmcnuwcdpmpertyst for impaction purposes.(We)agree m ase,indemnify and keep harmless the City of Cvpenmo against
Fl,i liebilitlu.judgments.casts e
and expenses which may in any way accrue againstaid City
V Z in mnscgmnce oroc gaming of this Permit.
�—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of Applicant COntsutor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle hasardoos material
as defined by tW Cupertino Munieiptl Cad,Chapter 9.13,and the Health and Safety
Allk.d.,SamaraYn 2553x25532a)? �No
7 All roofs shall be inspected prior to any roofing material being installed.
❑
Will the applicant or future building occupant an equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hasardous air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
strict?
❑Yes 0N
1 have maJ the harardous materials sequirent under Chapter 6.95 ofthe Califor.
niaHealth&Safely Cade,Sectians 35.A15.25533 and 25534.1 mMcrsand on rove Wilding
dors not currently have a moat,Nal it a my responsibility m anufy on=Up='of me
requirement.wmchmaslWmetpoormWaonceoraCcrdnamofOccapurcy. Signature of Applicant Date
OAll roof coverings to be Class"B"or better
Owner Or amhori'rcJ agent Date
CITY OF CUPERTINO r " • "" "" '
"BUILDING DIVISION PERMIT• CONTRACTOR INFORMATION: -
BUILDING ADDRISS' 3 0 , _ w PERMITNO�
�°'t GC T �D S 00080102
OW NCR S N {6!5 •- ' ' .. APPLICATION SUB DATE
IT iR V 08/14/2000
HONE,: - ' .. t SANT IARYNO. -11 CONTROL NO.
r G'oo ARCHITE T/ NGINEER r ,.R. `BUILDING PERMIT INFO
PP ca N - } - .BLDG ELECT, PLUMH� MUCH
.LICENSPD CONI'RACIOR S DECLARATION
CZc - II by fanftd tl' 1 'a e p rcmm donna -s + .._ Job Description
m dth5 f 7gq)dtD ��fUvH �S i 'C I dnyli '
,inf,.11ficarverem,• � �tl, s
oLLF p„" /�ems. G ," .I REMODEL REPLACE .TILE iNST,ALL SHWR VALVE!
4"7` ARCHITLCf S DCCLAI A �O ,
m �I ytl Ki,-ji
[an s Iltp he c6 ry�ublicmd,
w 00 LicelordProp...owl
OWNER-BUILDER DECLARATION rr ,
oi I hereby affirint that I nor exempt from the Contractor's 1 Law for in lr+
C a 5II 6 (Section 7031.5,U ...d Fort.. Code Any oil,or county I a + '
$S❑ which requires a l m 1 to construct,alter.improve,derrolish,or mental,scounum - •.
n3= prior i r . ' Lrequiresth pplic tf Ip li 11signedstatement
hat he is licensed parsurnit to the irwisions on the Contropear,Licens,Law(Ch t 9 S Pt. Floor Area '
(eo um
vg w,In Section 7000)of Dvi+ ,3 of NL Rlsnma and Poolev'enu code) ' q•, - -Valuation
orlist he e pt Ih f :d lne ba for the Il g d pf any v'el + - - ._vim. - .
orS i n703L5byaYapplicantCan v 1. bjects the Applicant ' cvlpenlp -
of +more than five h Bred dollar,(scan. •. - APN Number _ Occupancy'Type
❑1 raftbepr} ry' yenip ni with @
-g: . ' 1 j I " . ini p "+Nwill do the,work. d flic structure c, t intended or offwdf (Scit.7044 �'Req ...
Bl 1 Poll,... Cale:TheC , t L L d 1 t apply t � ulred Inspections
ownerfF ply Win)h Id' improves(hereon, h. d 1 k,finneW . ^
or lh gl n ply Provided thts h' p i ddb
offeredr l nh e t Wilds Idwhmonevector
'
101 —" FOUNDATION
completion,+huow lar b Id will have the burden of pan ns rent held nor bu'Id ' a /
mprmefiefpnmo.eor le). :".�:1¢12 — 0IERS . ,
Ll 1. lycnnedy mlicensed eal r .t103 — UFER'.
constructh prcj.('(Scc.7M4'Business I Ponfee,imar,Code)The Contractor's ! '
Lice L d nor pit rr r tr n hi p st n 104 — REBAR
mW h reclines f h p meas with. mmwI, ,) I I p uanl i +h• ,
codai :1 La x 105 —• ANCHOR BOLTS%,
Cl I an exempt aider S `,B 11&I Cfor this reasonI-"]tb6 SEWER &' WATER
Owner Date 10 A - ��
I WORKER'S COMPENSATION DECLARAI ION .. ,G02 'UNDERFLOOR `PLUMBING •"
sl hereby aBirn under penalty of perjury one nine following declarations: ._ , '?203 '-- UNDERFLOORMECHANICAL
❑ 1 n d. II mt a Certificate t fc In sdrann rn:•Work 204 UNDERFLOOR FRAME
Comp 'ation, as provided nor by Seciono 3700 nr the Union Code for par, L05. — UNDERFLOOR INSULATION
pcfr iinave ofib work f b'ch this permit I,N,cp&
301 ROUGH•PLUMBING
❑I n a Il mu n w k r c p r 1 . ne p t „02 TUB R' OR i SHOWER
3900 f th Q, l +h f f f th rk( 1ST ihi By r I is
'
XP e N p ( 1 d Policy number are
cit+er� P1 yN 303 — ROUGH' MECHANICAL.-
CERTIFICATION
ECHANICAL:
CERTIFICATION OF EXEMPTION FROM WORKERS " 3Qt4 _+(ROUGH ELECTRICAL
COMPENSATION INSURANCE r • p.'• 305 — FRAME _
"
his ton nein not bewnplued'fhit pernn iifor nic hundred dalton
fslntB rte's) - 306 HOEDOWNS
1 cedify that n(he'performance oftheworkforwmchtn pe r: 1 : 307' INSULATION' ' - , . .
'null et employ any person in any manner so w la become wb)wt to the Workers SHEETRc
- '
Compnnt L fewrt D o
Applicant n
-
NOTICETOAPPLICANTII after makingth Celf'to of'Excommor.you h Id 309 — EX'TERIOR`'.LATH "yl
I
z deco bI It Thew kc C p :'I p ¢rh L b C d y vt
O rnnnwmcomply who' Here .i' of th.pernm'llan Wed emea re.ow.a 3] 0 — , INTERIOR 'LATH -
O - CONST RUCTION LENDING AGENCY ` 3
'r
Z,
'11 —, SCRATCH COAT
aI Sereny fern that theremon,f leading aged)f he pn mnnu 513. — ROOF NAI L
of thek'for Melt ON permit e Issued(Set.3097 Civ.CJ
Lend Nan
a.Q ne
- 4 ;
p Z .Lend .nee , 501 'FINAL. ELECTRICAL'•ENERGY
o 90c — FINAL PLI..IMBIIvIG'. ENERGY
I rf5.ih t11 lth: ppr i d.l l tl tib M1 'nl' 'I
tas ,c. cnrrct I g i ply ithall 'my d ty d d rr I- bl b 503 -FINAL MECOANICAL ENERGY
eF0 V
inbtlldng t ( dl byauthn, i ut ib'.
llyi cnicrup •"' -
sy hermentioned p prty n.pef p p 504 ' FINAL• BUILDING ENERGY.
ity o
a liabilitesjds is celndl fy m,whkeei,hmay icitycwayrcle°geanto tsaii 505 —,rFINAL ELECTRICAL
U c'Iro v )e d'm s t L "mon
«'
ApiaOU C EGUYATIpNSNDS AND WILL COMPLY YWy3Ft.�1.L Nry INT rlSSlled by: P` 5Of''- —' GAS- TEST DBLe '
Slgdut,rAppl c HAZARDOUS
� _ _ jYY{//,Y/Dale, Re-roofs'• 508 - FINAL MECHANICAL _
HAZARDOUS MATERIALS❑ISCLOSIIR. '
.. will the appliicantorfnmtnbuimhtgo,mar(storeorhandle hazardous dldmdal Typeof-Rooftog,, `
o delndbythCiecul Mnaipmcon Griper,9.12,andm HalthandSafity - FINAL GRADE. e
Code.Sectionzssaz( ) I 5� F 1 L PLA N I NG .> '
°V - °N All roots shall b01 ected �Jr a r I mg ailed..,
whin pplcant I t b la'g ler t :ccquyp r Lie ce. which 'If'a rOOf 15 instal( it rou t SC- �aiiiWA s CGLLon, 1 agree to remove
emit h Mous an,wmu is as defned by the Bay Arca Air Qta'ry Man i6dnead - P �'
Dyes ' ❑No, - all-new maferiaN fol inspection;Applicant understands and wilbcomply'with
• - all non point source'regulations. ,
Irc'lth hoardnoncoms eI LL' I Ce
Cater 695 Irl
nf He ltl&Sof ly I S t :25505 25531 d 2.1534,I indder,haddLu
' fihc build' gd nl' Ilyh itthlt yr,p 'blryi Iffy lh _
Occup of t qt non nt h nun b t prt r to 's fn Cer'Irnl r f' - '
' ft/O,p Signature of Applicant, ' _ I f Date., -
omwn dd age I '�/• Dare All ilc; £coverttigs to be Class `B" or better
,OFFICE -
�. .. ,