02100133 CITY OF CUPEKIINO _ -- 'r
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
IUD. I DR6UND71ZLAND DR SARATOGA KITCHEN & BATH PERMITN®2100133
rlfrrs R,TAt,AND HENRY H AND ERIKA H 140 LEWIS RD. #10 APPLICAl ThOy77B2)1STTIy'Z002
PHONE. 4 1- 2 5 0 SANITARY NO. 7 CONTROL NO,
ARCHITC OINGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MP.CII
o o
VOp LICENSED CONTRACTOR'S DECLARATION
a-F I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing BATHROOM RE MUDT�Description
ya8 with Section 700(Bof Division Sof the Bwi i.,and Professions Codc.mal in,license is
mu c Jerre T Q$3Yo
ffvI�[lALk
—.1/ij. Gnu rji�it Lic.M � 5, p_ �
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Oi—O Ijv.i �0-17 —Ci Cn nor S ,7 a w Y Y
F��� t3 ARCf11lTCI'S 1� RATION
sSy1 unJcrsonJ my plans anal(he uuJ as puhlic rttnrda DEC 12 2002
FLLOg Licensed Pmfaxiored
OWNER BUILDER DECLARATION
vi I hereby affirm Thal 1 am exempt loom the Contractor's License law for the BUILDING $20000
ou 0 en following n a(Section 71131.5,Bufiinca and Profcsxions Cade:Any city or county ®I�IL�II V
a`<$ which reImo a permit In construct.Ober,improve.demolish,nr repair any structure
11—'^ print if its issuance.also requires the applicant far such permit to file a signed statement
that he is licensed puauenua the provisions of the Contractor's License Law(Chapter 9 29q2F3t)F&)bPAIQ0 Valuation
I"O Ictrmmcncing with Section 700(4 alDivision 3 of thc B.A....,and Pndessiom Coda)nr
it. $ that he is exempt therefrom and the bazis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penally of I UAPNN Occupancy Type
not more Nan five hundred dollars(SWk. 102 — PIERS
D I.as owner of the properly,or my employees with wages as theirsole compensation,
will do the work,and the strunart is not intended.roff=red fm sale(See7044,Business1 93
Re aired Inspections
and Professions Codmaces
Circle:The Conctor's License Law not apply to en owner of 104 - RE BAR q p
property who builds or improves thereon,and who does such work himself or through his
own employees,pmvJded lhatmch imprommentsare nofintended araffer=a mrsale.B. 105 — ANCHOR BOLTS
bowcver,the builiingar improvement is field within one year ofemanclnn,hemmer. 106 — SEWER & WATER
builder will have the burden of proving that he did not Wild or improve for purpose ofarlrf 202 - UNDERFLOOR PLUMBING
D I.as owner of the property,am exclusively contracting with licensed contractors or 203 - UNDERFLOOR MECHANICAL
Gourmet the project(Sea 70,14,Business and Professions Cialt The Contractors Li.
cense Law does not appy to an owner of property who milds or improves thereon.and 204 - UNDERFLOOR FRAME
who contacts for such projects with a convactor(s)licensed purstrant to lhecontractor's 205 — UNDERFLOOR INSULATION
License Law.
D lsed exempt under See. B&P C for this Ocrown 301 - ROUGH PLUMBING
Date 302 - TUB & OR SHOWER
WORKER'S COMPENSATION DECLARATION 303 - ROUGH MECHANICAL
k Iherehy affirm an&,renallyofpeyutycar athe following declarations 304 - ROUGH ELECTRICAL
D l have and will maintain a Cent feme of Commit it)stafff mure for Worker's Compcn- 305 — FRAME
sation,as provided for by Section 3701 of the labor Code.for the performance of Ne
work which this pe.it catted. 306 - HOLDOWNS
D 1 have and will maintain Workers Compensation Insurance,as required by Section 3 07 - INSULATION
3701 of the Labor Cole,for the performance of the work for which this permit is issued.
My Worker's Compensation lnsureocej�vier and Policy number ate: 308 — SHEETROCK
ca r'Arr -.d - C�an'Goa� 033700004TO 309 - EXTERIOR LATH
CF.RTIFICATEOFENEMPTIO ROOMWORKERS' E �/d 310 - INTERIOR LATH
COMPENSATION INSURANCE
(Thisucuonn=ed nolbearmplcterliftM permit isfnrone hundred doll.(1100) 311 - SCRATCH COAT
m less) 313 - ROOF NAIL
1 merofy that in the performance of the work far which Nis permit is ismad.1 shall an, 501 - FINAL ELECTRI CAL ENERGY
employ any Penson in any manner so asin Mcome subjecuo the Workers'Compensation
Laws of CaOBrnta.Date 502 - FINAL PLUMBING ENERGY
Appream
NOTICETO APPI.ICANr:It.after making this Cenilieam Of Exemption.you should 503 - FINAL MECHANICAL ENERGY
become Subject m the workers Compensation provisions ohne Lahr Cole.you mall 504 - FINAL BUILDING ENERGY
O O forthwith comply with such provisions or this permit mall be deemed revoked.
505 FINAL ELECTRICAL
CONSTRUCTIONisac uLENDINGAGENCY 506 - GAS TEST
[--t 1M1crchy affirm that franc
rc ismxwninn lending agency hmormancc o
the perff
W > the work far which this Permit isissued(Sec.3097.CoLC.) 507 - FINAL PLUMBING
nl 0 Lender's Name
CLI Lenders Add. 508 - FINAL MECHANICAL
UO l certify that l have read this application and state that the show Nmmmtion is 509 — FINAL GRADE
LL Pcorrect.l agree m comply with all cit and county mdinancea and fiate laws relating to 5 FINAL PLANNING
0U building coitmenon,and hereby authoim representatives of this airy m enter after the
r mshave.meminnedproperty far inspection puraves. 14 FIN PUBLI WORKS
fry (We)agree us save,indemnify and keep harmless the City of Cupertino against
rfA liabilities,judgments,ensu and expenses which may a any way scenic against said City
U in consequence of the granting of this permit.
r. APPLICANT_UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
lX0-0— Re-roofs
.ignal9re ofAppliaLA,.ARDOUS MATERIA1 DISCLOSURE Type
Type of Roof
will the applieam nr future building rweupam star=or handle hatallous material
ax defined by the Cupenino Mtca�ipal Code,Chapter 1.12,and the Health and Safety
de.See inn 25532m)? All roofs shall be inspected prior to any roofing material being installed.
DYes 5- Nd
I Will the applicant of future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit Infamous air contaminants as defined by the Bay Arca Air Quality Management all new materials for Inspection.
Disvicl7
E]yes 1ll4Mn
1 have read the harardous materials requirements under Chxpterti.95 of the Calilor-
niaHealth&Safcy Code.Sections 25505,25533 and 25531.l understand teal building
does not Currently have u tenant.Nal it is my resrymsibility to notify the occupant of he
Oniff. FyL.wTo hhmswhemelpp tniav an facenmeate^fa\cSignature of Applicant Date
"�(� �.�/�„�/ All roof coverings to be Class "B" or better
Owner or awhorl®J agent