02050035CITY OF CUPERTINO
stm.DWC DIVISION PERM*
CONTRACf0t(EWORMATW a "!.
BUILDING ADDRESS:
PERMIT N0,
22342 BAHL ST
GRIDLEY
COMPANY
02050035
OWNER'S NAME
MCSHANE THOMAS J AND BIRUTA
19 S 3RD ST
APPLIC9TION S DATE
05/07%2002
PHONE:
(408)374-0900
SANRARY NO. CONTROL NO.
' ARCHITECT/ENGINEER:
HULLOING PERMIT INTO
i
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Ihercby affum thnlun licensed ondcr provisions of CTeper9(commencing
�
REPLACE
Job pescn�ption
Wim Smion ]1100) vision3of the Bu�and Profe ions C°ee. ,nem license
a rs in PoII force and
6 WINDOWS/1 DOOR
j�an
m
- ` I u rsu y plans shal�bc uused E p _ An ds/O1�
� a �/
gym✓
.
11� �
I
JUN 2 6 2002
uanxd Proressionm
OWNER-exemD DECLARATION
from me
1 hereby affirm the, 11. exempt from the Convenors License Law for the
1 reason. (amino ID3L5, Business and Professions code: Any city or county
BUILDING $27000
which
9 which rcqu;ma r permit ne construct, aper, improve, fm.e, demolish. or repair any structure
a acouuoicesLadsnmmem
t.ba
dish is totethowisiosoffors arriCl
,kat he is nausea pursuenuo me provisions of me Convenor's License law 9
is o Business
Section ]rn
'3 a,'
ValUdllO❑
of ons(Chapter
and ny vi Code)
t he is
or thatexempt and t e basis
of thcrefmm and me basis for the alleged eaemgion Any violation
L'8.1'3'
V 7-C�
of Se ]031.5
31.5 b any applicant for a permit ac applicant a civil penalty
not iv
or not more than five n°nares desats (a5o0).
10 lAPN IPCDATION Occupancy Type
❑l, as owner of me property, or my employees with wages as their sale compensation,
102
— PIERS
will do me work, and the svvcmrc is no, intended or offered for sale (See. ]oast
Business and Professions Code: The Contractors License Law doo ss napply ,o w
10 3
— UFER Required Inspections'
Owner of proparty Who builds Or improves thereon, and who does such work himself
or through his own employees, provided that such improvements are no, intended a
10 4
- REBAR
offeree for sale. If, however, the building or impmvcmcnt is sole within one year of
105
- ANCHOR BOLTS '
completion, the owarW ilder will have ,he burden of proving that he did no, build or
improve for purpose of sale.).
106
- SEWER & WATER
01. as owner of the property, am exclusively contracting with licensed convenors to
202
- UNDERFLOOR PLUMBING '
construct the project (Sec. 7004, Business and Profession C°dc:)The Contractor's
License Law does no apply to en owner of property who Wada or improves thereon,
203
- UNDERFLOOR MECHANICAL
and who contracts for such projects with a Caron m(s) licensed part ent to the
c onvutors License Law.
2 04
— UNDERFLOOR FRAME
C3I am exempt under Sec. . B & P C for this mu,
205
- UNDERFLOOR INSULATION
owner Dale
301
- ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION
302
- TUB & OR SHOWER
I hareby arrrm under penalty Of pedo, ona Of following deelar it ons:
303
- ROUGH MECHANICAL
I have and win maintain a certificate of Consent to self-iomm for Workers
3 04
- ROUGH ELECTRICAL
Compensation, as provided for by Section 3700 of the Labor Code, tar th,
performance of the work for which this permit is issued.3
3 05
- FRAME
❑ 1 have and will maintain Worker's Compensation Insu arce, as required by Section
3 06
- HOLDOWNS
3700 of the Labor Code, for the perfomnance of the work for which this prom is
Worrell,307
My Workers Compensation Insurance carrier and Policy number arc:
- INSULATIOWorrell,
Crider. Poll, No;
308 .-
SHEETROCK
CERTIFICATION OF E%EMPI]ONFROMWORKERS'.
309 :
-•!EXTERIOR LATH.
_ COMPENSATION INSURANCE ' •
-" -310 ---INTERIOR-LATH-
flis section need not be completed if the permit is for one hundred dollars
(sl0o)oness.)
311 -
SCRATCH COAT
l a "'in errormmae nr the work rot hi thi�sy. mdt�s irsned, 1
313 -
ROOF NAIL _ _. ...
snail m empl° =yop n in arty ma er ao as o- eG c967E tYe'Ore workers
Compc sa,ion La f fit
501 -
FINAL ELECTRICAL ENERGY
Appliaan
502 -
FINAL PLUMBING ENERGY
None AP ret thisCenif¢atcofEaempaon,youshould
baonc� mWorkcri Compcnsev provivons of the laWr Codq you must
`
503 -
FINAL MECHANICAL ENERGY
ronnwi an wimsaanvrovisionsorwsamdt1.111deemedrcvoked.
504 -
FINAL BUILDING ENERGY,
CONSTRUCTION LENDING AGENCY
I hereby affirm that than Is a consWc4°rl leading agency for the performance
505 -
FINAL ELECTRICAL 1
of the work for which this permit is issued (Sec. 3(h9], Civ. C.)
506 -
GAS TEST
L,Mar's Name
Lenders Address
507 -
FINAL PLUMBING
1 certify that 1 have road this application and smm the, the above information is
508 -
FINAL MECHANICAL n ,
cores.) agree ter comply with of city and coamr prem nes o and state laws
tortidingardiorconstruction. and hereby aumodmmpaw,'. errs of thiscitytocnmrupon
509 —
FINAL GRADE
r upon
theaW(We)agioe
yandknpnrpoxa.
510 -
FINAL PLANNING
ve.rtyror
(We) agra<t vet indemnify entl keep hemdeu,hc City of Cupertino against
fimlbties, jaegma , a is and eapemas which may in any way seam, ,gains, sold
514 -
FINAL PUB IC WORKS
City th consegan of a granting of is pertni,.
APPLICANT IJND'R ANDS AND COM PLY WIrHALL NON- W
SO
Issued
1
S O
by:
Dale V V
`m" c°"""'°`
HAZARDOUS MATERWS DISCLOSURE
Re -roofs
Wi 1 the ppliant o fumrc building acupen, s,ox a hanmc hvardom mvuial
as defined CLpenino
Type of Roof
c Modcip Code, Chapter 9.12, and the Heahh and Safety
Carl coon 25532(a)?
'
'
O Yes - t
wu
All roofs shall be
inspected prior to any roofing material being, installed.
the appncamomtsoure Wnamd by the nay Area AirQn,oraevina emnt
mit hazardous air contaminants u defined by the Bey Arce An Quality Management
°isma,l
If a roof is installed without fust obtaining an inspection, I agree to remove
g
OYry
all new materials
for inspection. Applicant understands and will comply with
Y�
all non -point source
regulations.
1 haver the uWous rials requirements under Chapter sta of the
mauons
Clnfomia He &Safe code, See25505.25533 and 25531. ] understand
if the Wilding cartoon a— y have a tent that tenant i, is my responsibility to notify me
acupan, of orrequire ants hich mu be met prior to issuance of a Cenifica of
ignature of Applicant
Date
All roof coverings to be Class "B" or better
wrier., I d.,an Dine
OFFICE
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