02020078 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
21641 REGNART RD BLAK DORIS N TRUST02020078
OWNER'S NAME: APPLICATION SUB DA'I'S
BLAKE DORIS N TRUSTEE & ET Al 02/21/2002
PHONE: SANITARY NO. CONTROL NO.
COO ARCHITECT/ENGINEER: BUILDING PERMIT INFO
u C BLDG ELECT PLUMB MECH
ticu U LJ
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L O vNi z LICENSED CONTRACTOR'S DECLARATION Job Description
11¢rcby uffrm mat Into licensed under prwrisions of Chapter 9mmmrcing
,nl_c aithSection7001wfDivision3oftbcBosirmorradPool'c..mn,CodeandmyUmme ADD GAS LINE TO FIREPLACE .
a—i, is in full force and effect.
r s rc 6 License Clan Lic.is
Date Commmnr
ARCHI'TECT'S DECLARATION
Y m Y ; 1 uWmtand my plans shall be uxtl as public«cobs GA
L° o 0 Limnsd Professional V�s
OWNER-BUILDER DECLARATION V
w to to 1 hereby anon that I am aaempt from the Contractor's License Law for the
C?< following renown.(Smtiwn 7031.5.Business and Prefenio®Code:Any city or county
F G which requires a permit to construct.alter,improve,demolish,or repair any structure 6 0
i 3 w -pnor to itsq ' S[he lippliont h promir toFile a signedswument
Ihathc I esiv a leo the vi' n.effe Cmdowon,License Ls (Chapter9 s, S Ft. Floor Area-., .g Valuation
(commencing moths t 7000) rD 'k 3 rn Baltimoredo fe ns Codes f_(Mti,"S'j ,ji. $rtlt ik✓'.Z;
or that be n exempt therefrom and the basis for the alleged elemynoa.Any violation '3�5 22V14'
: O'O
-of Section 7031,5 by any applicant for a permit subjects the applicant to a civil Penalty
ifnm mnxman fire hundred dollars($500). APN Number I--r . . ..• Occupancy Type
la Las ownerafine r.or tis,amincaswhm am mdrawlecom anis. 106 - SEWER & WATER
grope 5 ) p Y gesas pansy
-'Busingll-do theoil Pm,and the struode Th C not intended d or License
La doe sale(Secapply
9111ki.an - --- - - - ..
Business oil Pmrevsiatls cage:The crmmolnr'a ureas Law d«s ern apply to an 301 - ROUGH P spec ons'. -
owner of property Who builds or improves thereon,and ono does such work himself
or through his own employees.provided mat such improvements art not,intended or 302 ._.TUB -&-OR- SHOWER-
-'olfered'I.,sale:IC however,the building or improvement is sold within one-year of --� - "'-'-------'_._....._ _. ....\ ,._... _. __..
compiniwn,the owner-budderwill have the burden nfpmving that he aid not build or 502 - FINAL PLUMBING ENERGY '
improve for Patt of sale.l
s" - - __y. - -- 506. -._GAS._TEST._. .._ . ._ . -
coLasowner wane p(Sec.7am Business wswrly and
with --- -
Lira. the project(Sec.moan Baseness and Professions code:)The Contractor's 507 - FINAL PLUMBING
`L r
and-wh Law docs eta apply m an sets w of progeny who builds se impmvee thereon,
end who contracts.for such projects with a contractors)licensed pumuanteo Ito .._. .. . _ .._... .... . . ____,._._..__ ....._ _.-.. .. ....... ...._
_ C nrs Licenx law: .
_ Ell ..esI am exempt under Sec. :B A P C for this reason
owrim, Data '
WORKER'S COMPENSATION DECLARATION
1 hereby a1Brm under penalty of perjury one of the following declarations:
O 1 have and will maintain X Caroni of Consent oto self-insure for Worker's
Compensation, as provided for by Section 37W of the Labor Code, for the
performance of the work for which this permit is issued.
❑1 have and will maintain Worker's Compensation ldsurance,as required by Section
37W of the Labor Code,for the perfomm see of me work for which mis permit is
issued.My Worker's Compensation Insurance carrier and Polity er numbare: _
rPol'.Yyc _... .. c r.,r, 1C.Si-�:�;A'i t�� �:,;..1 it:ct s S :`i i;'.1 ., . ..
y CERTIFICATION OF EXEMPTION FROM.WORKERS',' -
-�. COMPENSATION INSURANCE'` a ..-
'(TM1ia sicdnn nccBnni he ntmplctN Boom permit is fm one hundred dollars '.'_LI 'U, Pi.. '
161 WI.''less)
I ttmplomet in me performance of the seas t for
cg1 this pemrit c issued.I -
•hall not cmployany Person in any s m become subject m the Workers'
yre qct a
fompcnsmiwn L;nvs of Califnmio.Detl1 'A-L/-OL '
-Applicant:' /)vis. C AGC✓.'N " "
NOTICE PLICANT:If.after making this Ccni&am of Exemptionyou should
become subject the Worker's Compensation provisions of the Labor Code,you most Q 0 fdnhwito comply with such provisions or this permit shall be deemed revoked.
... .._. -... .. .. . ... } . -. .-..- . __ . .. ..
Z. it .. ....1-.._
'F N iia" s CONSTRUCTION LENDING AGENCY, ; '
4' I hereby affirm ch this Inert is a bmid(S ion lending agency for the performance
k7.n.t horn k for which this p t "sued(Sec 709),Civ C) _ _ _ -,. _ _,_,. -,. _. - .- _._.-
0..❑ -Lend Name' .. .. . .. ',. :I ....... .. ...... ..... ...
5 z I-solder'sAddrari
.V Q I cenifythat l havemadthis applicat ion and state that the above informationis
'correct.I agree to comply with all city and county,ordinances and state laws relating
Q [) to building em motion,and hereby autborme icpresentatives of this any to enter upon
iy Ls7
the above-mentioned prepcny for inspection purposes..
�.ps (We).9.loses.indemnify and keep harmless the City 6f Cupertino again
V) liabilities,judgments,costs and expenses which may in anyway accrue against said
U Z City in consequence of the granting of this perinit.' '
APPP:IpCLANNTT ONDERSTANDSSAANND WI COMPLY WITH
1'ALL
{NON(y�OINT Issued by: r Date
ignarre'ifAppLFanvcwntraetar, Das Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or ficturetrildirg wcc laint'stom or handl haavdous material Type of.Roof
as defirsed by he Cupertino Municipal Code Chapter 9 12 and the Health and Sam ry ) �^
.Code,S t 25532(')1 Y' '( I '1 �s Vat' f 1- ti.l_t•
CI Yet t 'I t N „v;, sd i , _ All roofs.'shall be inspected prior to any roofing material being Installed_. .
wpm ppi�eo r� aloin{ pa t�xeq�p to a- a.'hicb, If a roof is installed without first obtaining awinspection, I'agree td remove
emth wd -s oat mnnt. defined by the Bay Area Air Quality Management
DimIrc . . , all new materials for inspection. Applicant understands and will comply with
°v0, X"mall non-point source regulations.
I have read the hiiandous materials requirements under fChaplco6.95'of she
Califomia Health h Safety Code.Sections 25505.25533 and 25534.1 understand that _
Ifinebailding does not currently have e¢nnnL that it is my responsibility to notify the
occupant oLme requirements which must the met prior to issuance of a Cenifi1.cam of
'"
' " . t�. -t Signature of Applicant Date _
"'f.. wed aamnri:edagent ..). .. .!u _ Data. All roof coverings to be Class`B"or better
^' OFFICE