01050141 ERTINO
CITYBUILDING DIVISIONPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10868 NORTHSHORE SO. 01050141
OWNER'S NAME: APPLICATION SUB DATE
JUDITH HART R KEVIN AIT EN 05/16/2001,
PHONE: SANITARY NO. CONTROL NO.
ZO ARCHI'I'ECBUILDING PERMIT INFO'DENGINEER: BLDG ELECT PLUMB MECH
u D 1-1 G C7
G�Z 5 El Z LICENSED I a CONTRACTOR'S DECLARATION Job Description
tJ Ei y I heathy on the 1 oro of the under provisions of ns Code, ad my here g
F y f— is in Section led of Division J of the Business and Professions Code,and my license
Q Lid,r nfnreeanaerree` KITCHEN REMODEL. -
Hu 5 s Livens Class Lic,p
Date Cormaemr MOVE NON—LOAD BEARING KITCHEN- WALL.
ARCHITECr'S DI!CLARATION
g 1 undcamnd mY plane Nmll w used ns public remN.v I , .p.+�, p` t. 1
par O O Licensed Professional
fi OWNER.BUILDER DECLARATION
u1 1 herthy affirm Mm I^m dumps from the Commcmr's License Luw it Ot
C Z a following reason.(Section 7031.5,Bwiness and Professions Cade:Any city a,
I F G which requires o permit to construct.alter,improve,demolish,ar repair any rot tore
prim to its issuance.also requires the applicant for such permit to file a signed sta est _ 1
mm he is aeenaW parsaantmme pm.i,iom ar me conuaenora ucenxe ldw(Cil q. Ft. I Ar Valuation
(commencing with Section 7Wd or Division J of the Business and Prefessiena _
or Ihm he is exempt therefrom and the basis for the alleged exemption.Any violation
of Section 7031.5 by any applicant far,m permit subjects the applicant or a civil penalty
of not mare than five hundred dollar.t$500). APN Number Oeeuparw8
Ky��x
owner of the properly,or my employees with wage as their role compcnsmion,
n'Ine Ilio work,and the stmcwrc Is not intendedLi or offered for role(Sec. to7044.
so
nminr,x and property Who b Code:me Caetmctorx,anew Law does not apply m an 36]38037 R@t(pired Inspections
owner w'property Who buildsnr improves thereon,and who docs ouch work himself
or through his awn employees.provided that such improvements are not out year or
coerce for rule.IL however, he lmiave t m improvement ingsoldthe.within one year of 101 — FOUNDATION
completion,the owner-builder will have the burden of proving the he did not wild or
improve for purpose or sale.). 1.02 — PIERS.
°I.as,ownet of the property,carat exclusively contracting with licensed comments to 1.03 — UFER
Lnstruct the project(Sec.]BW.Business and Professions Cade)The Contractor s
ivens Law d«,not apply loan owner of pmpery who wilds or improves thereon. 104 — RE BA R
and who canemeta for such projects with a contractors)licensed pursuant to the
Contractor.License Law.
°l am exed e- B&P C front,rears 105 — ANCHOR BOLTS
Owne,�n;,te 6 /��p / 106 — SEWER R NATER
oR ER'3COMPENSKI'ION TE I. RAno" 202 — UNDERFLOOR PLUMBING
Ihereby mnirmunder pnwryn eiaryomeofinefouowiagdenmmhmt: 203 — UNDERFLOOR MECHANICAL
° I have and will maintain a Certificate of consent to ser-theme far Workers 204 — UNDERFLOOR FRAME
Campenmtion, as Provided for by Section 37M of the Labor Code, for the
perfacomove lithe walk forwhichmispennit is issued. 205 — UNDERFLOOR INSULATION
°1 have add will maintain Worker's Compensation Insurance.as required by Section 301 .— ROUGH PLUMBING
37M of the Labor Code,for the perfarmance of the boo&for which this permit is
issued.MyWa&ersCompensationInsurancecarrierandPolicynumberam: 302 — TLIB R. OR SHOWER
Carrier. Policy No.: 303 — ROUGH MECHANICAL
CERTIFICATIONCOMPpNSAITONINSURANCE F EXEMPTION FROM WORKERS' 304 ROUGH ELECTRICAL
(Has section need not Ind coniucled if the perinin is for one mtndred dollars 305 — FRAME
(S10IOnlecs) 306 — HOLDOWNS
I seedy mann the pedomaace of the work far which his Permit is issued,1 ^07 — INSULATION
shall mancone, m bme
[employ any person in any rmner so us ecosubject m .Cr
the Workers'
Compensation Lawsarcwiramm.Da" 308 — SHEETROCK
NOTICE TO APPLICANT.If.after making this Certificate of Exemption.you should 309 — EXTERIOR LATH
become subject the Woers Compcation provisions of the Labor Cole,you most
O C tt & m
fbh
arhwconplywithsuchprasWan,is,In, erom, but]Wdeemedrevowd. 310 — INTERIOR LATH
Z
F; CONSTRUCTIONLIiNDING AGENCY
a; 1 hereby of0rm that there is Cnll,lLHNlending agency ria Ilia palimmm�cc 31.1. — SCRATCH COAT
of the work fur which this permit is mord(Sec.3097.Civ.Cd
boy Lent:.baud 313 — ROOF NAIL
Z Lc ticrxAddres 501 — FINAL ELECTRICAL ENERGY .
G Icenifythatlhavelead thisupplicminnandn,aid that hcabaveambulant ik 502 — FI61AL PLUMBING ENERGY
W f~" coma.1 agree to comply with all city and county ordinances and stere laws relining
O U mbuilding conswctied,and hereby authoriaerepresetnetivesofthis city toenter upan 503 — FINAL MECHANICAL ENERGY
W the above-mentioned pm,,ey for inspection purposes.
9W (We)agree or saw.indemnify malkeep Iodides,the City ofCuarino.,.air, 504 — FINAL BUILDING ENERG�
in liabilities,judgments,costs and expenses which may in any way name against said C
uz City incmix ranee of hegmmmgofthis Permit. 505 — FINAL ELECTRICAL
4A,PPL4NTU D (STAN SANDWILI,COMPLYWITHA LN •POINT Issued by: Date. /otAt ,hcant/Comr:eor Date Re-roofs 507 — FINAL PLUMBING
HA'LARDOUS MAD?RI",DISCLOSURE
Will the applicant ar mmm wildingacupare mom ar wtWle havmlon,dtaterml Type of Roof 508 — FINAL. MECHANICAL
s defined by the Cupertino Municipal Cal ,o
Curb.Chapter 9.12ld the Heahh and Safety
Code,Section 25532(a)? 509 — FINAL GRAD
°Yes °No All roofs shall D� sets ipp Eo serial beim installed.
Will thea applicant or(wore building recu am use equipment or devices which @p � IVH b aR g
pp g pIf a roof is ins[ witho,1rf [$[�4 t<f l a spm"�fr�ff{Q�s.1f agree to remove
emit haaaNaus air comarommas as defined bythe Boy Area Air Quality M...leaned 4. t IV fits. ,fSeUDiyy yyy,f Qfs�
District all new materials or in7l I ❑ kpttt 11'I000888IIIllll DUerJ(AItUU11 aaI1I'd will comply with
°Yea °N.' all"non-point source regulations.
I have read the heamduos material,requirements under Chapter 6.95 of the
cmifomia Health&Safety Code,Sections 25505.25533 end 25530.1 understand than
it]he building does not cumid,have ntcamathus it is my responsibility( nnJfythe
,do'cenpuol of the r ry conn With incl he mel prior m issuance of a Cenllierle of
Date
5 O Signature of Applicant
Can mac agent ;rte All roof coverings to be Class `B"or better
OFFICE