02110089 CITY OF CUPERTINO
BUILDING DIVISION PE110TJ:
TON-
BUIWlJj[q)A&0_RESGREENLEAF DR REINSCH ROGER A AND SARA E PERMITNO2110089
OWRBI99CFFROGER A AND SARA D APPLICATTIVYTRYY 2 0 0 2-
ONE; SANITARY NO. CONTROL NO.
ARCHITECT'/ENGINEER: BUILDING PERMIT INFO
ILDG ELECT PLO
LMECH
H02 LICENSED COWFI�ACTOF�S DECLARATION
i- I Itemby affice that I am ficensed under provisions of Chapter 9(commencing KITCHEN REMOD Ab Description
�ZU flub Section 7")ofDivision 3 of its,Business And Professions Code.and my license is
j�_� in full furce.nd Aff.t.
Zon License Class—Lic.0
Oz Dam Contractor
MM= ARCHITECTS DECLaRATION
� I understand my plans A
as hall W used as public records A
to
JUL 13 2003
OWNER-BUILDER DECLARATION
rcI hereby Alton,that I Am exempt from the Cononator's License Law for the
or
KKOO following mason.(Section 703 1.3.Business and Professions Code:Any city or county $19000
�S( which requires a Permit in construct,alwr,mi demolish,or repair any structure BUILDwr,
1-Z< prim,0 its isamunce,also requires ft applicant for such Permit torileasignadItAlmonein
5 that he is licensed pursuant I.the provisions of the Contractors License Law(Chapter 9 3S261516MOAAffiD Valuation
uOCsProfessions Codc)
that ha"is exempt therefrom and the basis for be alleged Cameroon.Any violation of
Section 703 1.5 by any a,upficturn for.Permit subjects the applicant re a civil Penalty of
no,...than fivi hundred dollars(M). 1 U APN 09WDA UN Occupancy Type
0 102 - PIERS
will do one wore.
and uthe stroctum isnot intended oroffired fortude(Sam.7044.Hastiness 1:83 UFER
and professions Code:The Contrater's License Law does not apply to An owner of 104 - REBAR Required Inspections
property who Wilds or improves tharesmand whadoessuchwoulk hirmalforthrough his
Own employees,Provided that much improvements am not intended orollsond for sale.If, 105 - ANCHOR BOLTS
however.the Wilding or improvement is mid within one year ofeampienon,the mari
Innidar Will have the Wman Of proving that he did not Wild or improve for purpose,of 106 - SEWER & WATER
Ai 202 - UNDERFLOOR PLUMBING
0 L 03 manat Of the PmPcrty,am aaciuslw[Y consawfing with licensed contractors;to
construct be,pmjcct(Sec.]Odd,Business and Profession Code:)Tim Conesucte's Li- 203 - UNDERFLOOR MECHANICAL
ccnw Law does not apply to an owner of property who Wilds or improve&insemon.And. 204 - UNDERFLOOR FRAME
who contracts for such projects with a conessuctor(s)licensed Panama in the Cmaracutra
Law. 205 - UNDERFLOOR INSULATION
kolrmr\mpturdarL��.B&Pcf In 301 - ROUGH PLUMBING
Dai 37
Owme, L I ?:
te 302 - TUB & OR SHOWER
tl�WOR.ERS COMPENSATION DECLARATIO
I hereby affirm madia, mah,Of arpoy cas of he fat
I miatnumns: 303 - ROUGH MECHANICAL
(-' J will maintain aCtifificaaacdConemnot if-Warm for wormes Com 304 - ROUGH ELECTRICAL
have
Compen-
sation,As provided for by Section 37M of the Labor Code.for the Performance of the 305 - FRAME
work for which this Permit is isrood.
0 306 - HOEDOWNS
1 have and will maintain Woran's
rCompensation lammunce.As requiredrequiredby Section
37M of the,Labor Code,for she performance ofoo,work for which this Permit is issued. 307 - INSULATION
My Warines's Compensation Insurance carrier And Policy number Am. 308 - SHEETROCK
Carrier Policy No: 309 - EXTERIOR LATH
CEIMFICATE OF TC
MMOM WORKERS'
COMPENSATION INSURANCE 310 - INTERIOR LATH
Or We.)Cruirr section need not he ciarph,tal if the permit is for one hundred dallars;($100) 311 - SCRATCH COAT
I century that in the perfoup6ni'a of ffic..ok for which this Permit is ismed.I mail net 313 - ROOF NAIL
employ any Awn t.%7marnsr. rab!�PT b twftWorkers C paramour 501 - FINAL ELECTRICAL ENERGY
m502 - FINAL PLUMBING ENERGY
Laws of Calif Ic
AP lic
No TO Pin 11.Itfuer rnalin, rsCertificate of Exemption.you sdwuld 503 - FINAL MECHANICAL ENERGY
become subject to the Worker's Coarreamition provisions of the Labor Code,you must 504 - FINAL BUILDING ENERGY
OO forthwith COMPIY With Such Provision or this permit shall W deemed revoked.
z 0
P M CONSTRUCTION LENDING AGENCY 505 - FINAL ELECTRICAL
1 hembY affirm that them is.c.morm,,tion leading agency for the Performance or 506 - GAS TEST
Ix ffic work for which thia Permit is issued(Sec.3W7.Co,C.)
Leader',Name 507 - FINAL PLUMBING
Leader's Address
�Dz 508 - FINAL MECHANICAL
U 0 1 certify that I have mad this Application and mine that the above inrormuinn I.
11 P: correct I-go-to Comply with All city and county ordinances and state laws Wing to 509 - FINAL GRADE
o U Wilding construction.and hereby autionim represcrobvm;Of this City to entc'eupom the 5 FINAL PLANNING
w Wvt-.tatiupeny for impactor,purposes
0. (We)agree to saw,indemnify and lomP hismalmS the City or Cupertino against 14 FIN PUBLIC WORKS
IZ) Liabilities.judgramous,cowing ispenact which may in my way Am—Against said City
Uz in consequence of on,granting of this permit
6PNICANT UNDERSTANDS AND WILL COMPLY WITH ALLliN-POINT Issued by: Date
vV
;U ULA
7— Re-roofs
a%,nBo�APPbcamvCor`mCoo am
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding becapart store or handle Incestuous material T�p�of Roof
a datincut by she Cupertino Municipal Code.Chapter 9.12,and the Hulth and Safety
Code,SccLum 25532(.)?
0 year PrNo All roofs shall be inspected prior to any roofing material being installed.
Will she applicant or future Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
t hazardous air contaminants As defined by the Bay Arco Air Quality Management
ment all new materials for inspection.
0 Ws f"Nrt
I have read the Im.d..br-lcli-b acluirchomts tode'Cluiln,'6.95.fft alifix.
'M 'a if'
no '�&Sac'YC�.�OMZMS,25533��5�.lun��ifft Wilding
, is try the;
have.1 . rd,W A ni,deatitermyrespobibibbyro Ouryt,cecupamorthe
vi c orm' ran C
man.which 9 1 Prior—
A, in issuance Carl upan
Signature of Applicant
Date
A.
Owncror unhodndagent ate All roof coverings to be Class"B"or better
OWNER-BUILDER VERIFIC100N
1. (Check one) I or my immediate family(parent,spouse or child)will perform:
• A. All the work authorized by this permit
B. _ A portion of the work
C. _ None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. _ A portion of the work(complete section below)
Contractor Address/City Phone # State License # Type of work to
be performed
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
• portions of the authorized work. I understand that I may be an employer(see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.,
Person/Firm Address/City Phone Number Type of work to be
erformed
.............................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information(reverse side). f /
Property Owner's Signature:
�� !ZZ Date:
Job Address: / r( Id Permit#Any chanties to the information urovidedon this orm shall be submitted to the Cityof C
Department.
p
' CITY OF CUPERTINP
CITY OF PERMIT APPLICATION FORM / too
CUPE(�TINO
APN# Date:
&✓ ✓3. 2Do�
Building Address: ^� 3
Ow�e� s_Name: Phone #
l MEK RE/Av SUk q00
Contractor: License#:
t'�t�7'►.Q.r�i
Contact: Phone #:
Applicant/Contractor: Fax #:
uil n Permit Info: -
Bld Elect - lumb
Mec
J escript•
Residential K ITr,µ ��o a L
Commercial:
Sq.Ft.Floor ea: $/Sq.Ft.:
Architect/Engineer: Valuation:
Type of Construction: Occupancy ro p:
QuantityFee ID Fee Description Fee Group
BAPPLOTHER Other A liances MECHANICAL
BCONSTAX Construction Tax BUILDINGm
BCONSTAX Ind/Off/Com/ uasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
Ba. BELECIOOI
NSTAXH Hotel and Motel BUILDING
STAXR Constax-Resi/Mobile . BUILDING
C1000 Elec 600V<= 1000A ELECTRICAL
Elec 600V> 1000A ELECTRICAL
C200 Elec Svcs 600V <= 200A ELECTRICAL
RGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. HousingMit. Fee BUILDING
BMITIGATRE Res. Housin Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
BNEWMULTI New Multi-family Res ELECTRICAL
BNUCOMME I New Comm Electric ELECTRICAL
BNUCOMMM I New Comm Mechanical MECHANICAL
BNUCOMMP I New Comm Plumb PLUMBING
76
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