02100198 CITY OF CUPERTINO � a +*• `. �%�%'
BUILDING DIVISION PERMIT W'CON CTOR°INFORMATION r.,
� .
Bulq)gI/190'EsANNE LN RON WALKER PERMITNO 2 10 0 19 8
4NANWALKER 19160 ANNE LN APPLICAT216SN"TY2002
E.
PHONSANITARY NO.// / CONTROL NO.
ARCHITECUENGINET:R: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICEN0 0 0 0
woo dim rivSEDCONTRACnOR'SDECLARATION bDescri IIOn
1 hereby affirm hal I am liecnad ander provisions of Ghdplfl Y(commencing p
9z<u with Section 9ggpofDivishm 3 of he Business and Pmfeasinns Cmle,anamyreenae is ADD SPA TO PO
in funs force Cla and effect, F 9 N A LE
I- � License follClass Lic.M
0XI:aA
Date Contractor
gg�
s shall EC TS DECLARATION APR 1 0 2003
< 1 understand my phos shall be used as public records
L.3au
r=0< Licensed Professional
OWNER-BUILDER DECLARATION
un
sa S 1 hereby aflirm that 1 am exempt from he Con ructofs Liecna Law for he MOM WE po fallowing reason Section 7031.5.Business and PmfWsions Code:Any city or county ®HS141 9NG�.1
x m which"cies a Noun to etmafiuet,alter,improve.demolish,or repair any structure
prior hr its issuance.also requires the applicant for such permit to file a signed sta¢mcm
E£i< that he is licensed pursuant othe provisionsofthe CmuseLer'sLicense Law(Chapter 9 3S115Et7I0dT2A@1D Valuation
y l-� (commencing with Section 700 )of Division 3 of he B uciness and Professions Core)or
y Beat he is exempt hemfrom and he basis for the alleged cacmprion.Any violation of
Stetion7031.5byanyapplicarefura pmmirsubjects the applicant o scivil penally ofOGeDdnC
not morn dam few hundred dollars(S51n). 102PMNPIERS Occupancy Type
C] 1,as owner of he property,or my employees with wages u their sole compensation,
will do Ne work,and he structum is not intended or offered fur sale Ili 703Q Business
and Professions Codi The Contractor's License Law does not apply to an owner of 104 - REBAR Required Inspections
properly who(wilds or improves theme ,and who does such work himxlf or mmugh his
own employees.provided that such improvements am not intended or offered for sale.If, 105 - ANCHOR BOLTS
however,he building or improvement is sold within one year of completion,he owner-
beilder will have the burden of proving Beal he did not mild or improve for purpose of 10 6 - SEWER & WATER
sal`.). 202 - UNDERFLOOR PLUMBING
❑ I,as mvncr of he property.am exclusively contracting with licensed contractors to 203 - UNDERFLOOR MECHANICAL
construct file project(Sec.70dd.Business and Professions Code:)The Contractor's Li
se Law Mas not apply toanowner ofproperty who Wilds orimprove,thereon.and 204 — UNDERFLOOR FRAME
woo Donets ter such projects with.Waoxclorts)ucenwu
d pnauano he Coaranm's
Law ' 205 — UNDERFLOOR INSULATION
mcx mon B&PCforthisreavon 301 — ROUGH PLUMBING
On I/JGL� Ef Date D— I-01/ 302 — TUB Sc OR SHOWER
WORK ER'S COM PENSATION DECLA�RRyy]T-1]n��N 303 — ROUGH MECHANICAL
I hereby affirm under penalty of perjury one of the to ng dcelaaunna: 304 — ROUGH ELECTRICAL
❑1 have and will maintain a Ceni Ileac of Consent to self-insum for Worker's Compen-
sation,0 provided for by Section 3700 of the labor Code,fire the performance of the 305 — FRAME
work for which this permit is issued. 306 — HOLDOWNS
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3 0 7 — INSULATION
3701 of the Labor Code,for he Performance of the work for which his Permit is issued.
My Worker's Compensation Insurance carrier and Policy number am: 308 - SHEETROCK
Carrier: Policy Nor: 309 - EXTERIOR LATH
CERTIFICATE OI'EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 310 - INTERIOR LATH
(This action need not M Whillete)if the term it isfnr enc hundred dollars(S 100) 311 - SCRATCH COAT
or let313 - ROOF NAIL
la'cnify hal in the pear inter so as wnrkforwhich his o permit is issued.Compensation
501 - FINAL ELECTRICAL ENERGY
employ any pe son inner so as to Mromc suM1jeeun the Wnrkcrs'CnmPensatlon
taws orcaluorrya. t S02 - FINAL PLUMBING ENERGY
Applicant nth L (L
fvsVOT ETOA�PLICANT:ILaftermaking this Certificate MExemption.you hold 503 — FINAL MECHANICAL ENERGY
1 c Subject m the Workers Compcwtiun provisions more labor Code,you most
OZ Forthwith Complywihitshanh
suchprovisionsorhispcmedeemedxvwdvd. 504 — FINAL BUILDING ENERGY
z O` CONSTRUCTION LENDING AGENCY 505 — FINAL ELECTRICAL
F Iherehy affirm that here is a construction lending agency for the performance of 506 - GAS TEST
tZ >
'he workfor whichlhispermit isissucd(Sec.3097,Civ.C.)
W Lender's Name 507 — FINAL PLUMBING
Q
] Z ndr'sAJJrese 508 — FINAL MECHANICAL
U O 1 certify hal I have read this application and state that he above information is 509 — FINAL GRADE
ly F correct.l agree to comply with all city and county ordinances and state laws relating to
OU building construction,and hereby auBendrerepresentatives ofthis city tocome upon the S FINAL PLANNING
abovementioned property for inspection Ponmscs.
H agid
gate m save,in
and k ep haminss the City of Cup rtino against 14 FIN IC W RKS /
r'/1 liabigun c tscora and cxpenas which may in any way accmc against sail CIyin coceo th g'andpS thisPermitAPP ND BSPd 'DS AND WILL COMPLY W ITti ALL NON DINT Issued by: DaSOUG
l 1-0L Re-roofs
Signawre of Apprcanvcommelor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant nr future building eceepant ntme or handle haratlu s material
JefineJ by the Cupe)Prtino Municipal Code,Chapter 9.12,and he Heath and Safety
a.Sccrinn 255J21a
11 Pr ❑Yes ANo All roofs shall be inspected prior to any roofing material being installed.
Will he applicant or future building«earner use equipment or devices which If a to Ais installed without first obtaining an inspection, I agree to remove
emir loWardous air contaminants as defined by the Bay Area Air Quality Management all ne aterials for inspection.
District? / P
071,s �r
e rect)he harardnm'ernmW alsmyuircmcnu under Chapurfi95 of BeC Cnlifor
ria Health Sac Coak.Stt. s255o5,25533and255M.Immorandtdmifhc building ,\ r'
Ah
I hu re I.thin it u mY rcsP+raibility m nndly he rav'upanl of heKE1AAW /0 Al Ve nnrloiaeanCe.faCe Teateoraenrancy Signature of Applicant Date
a hmi,edagenr 0 3Q, DZ All roof coverings to be Class "B"or better