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CI uul o nc OF DIVIISSIIONNOPERMIT
CONTRACTOR INFORMATION:
BUILDING ADDRESS:
PERMIT NO.
4
OWNER'S NAME:
APPLICATION SUB DATE
CHANG JENNIFER Y
02/13/2002
PHONE:
SANITARY NO. CONTROL NO.
ARCHITF.CT/ENGINEER:
BUILDING PERMIT INFO
-
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I ]Ob Description
P
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Senior ?000)ofDhmic.3oftheBusmersandProfession, Code.and mylicense
to full force cola err«t.
-ENCLOSED PATIO
[is
License Class Lic. p
Date Commoro,
�''`'
It—'�p/� tr
9
9 �C
_v
ARCHITECT'S DECLARATION
o'4 kin. 1>_
1 underoand my plans shall be used as public records
SEP 17 2002
5 Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm, that 1 am exempt form the Contractor's License Law for the
following reason (Semon 7031.5, Business and Professions Code: Any city or county
whM1eq er[t teptllihor repo any structure
a
BUILDING $15000
III I.iiii,indstausni
�,•1. Sq . Ft.,Floor-Area• vAI if
Y�(�,`v j r. 'iZtkAt�� a`Cs:
Valuation
Nal he elcertvA inuistuarl allpro ', n lthe Commumer Licento La (Chapter 9
(co c g th Sort ],000) fDlvulon3 (th B e dPofe n Cnde)
or that he Is exempt therefrom and the buss for the alki,11 ezemppoo Any ,volar on
3 619 1 2 5 : 0�0
t
of Section 7031.5 by any applicant fora permit mhjeeu the opplicont m a avis penalty
'oInoomore manfile hundred dollars (s50o).
APN Number
I.r::. Occupancy Type
property,
01. as owner of ,.ores Mees with woes as their sole [oro UI nn
ywct Y
101 - FOUNDATION
; "
'wilt Orde k Ne :P o� intended or oRerte forsale 'IS c' ]Ula
-Buse
- - - - - - - - - ------ - __
d Profies,ions Code. The Contractor s License Law does not apply to an
Who
Required Inspections n -
103 - UFER
owner of property bunds or Improves thereon and who does such work himself
or m sn n- employees. p v i - t n p t t , yjar or
., nc r hiscideif, h sh b ul ng p e sold within )ear of
-p1(
..__-10 4- - REBAR------- - -- ------ -- ------ -- --
cr m bolder ill have 'he burden riffraff.,mtn tee mild
105 - ANCHOR BOLTS •` - a"
int o r v ris fm1e)
/p _
_.... 106_.- SEWER...&..WATER_
pp 1 as f Ili propenK air exclusively contracting with licensed commercials to
k t t theProject (Se[ roil Business and Professions Cm) The c t t .
__ _.
-"�_ 4 - ---
202 UNDERFLOOR PLUMBING
- License Law docs not apply to an owner of pmpeny who Wild, or i ..proves memoq
and who contracts for.such projects with a.co poicar(s) licensed pursuant to.Oe-
203 - UNDERFLOOR MECHANI CAL
Can tm toe u[enxL
' ❑1 _ pt ury r B'&PCf tars reason
204 - UNDERFLOOR„ FRAME... _.... _..._
�221%�'�
owne:' Date a�'=u_`�
205 - UNDERFLOOR INSUliATION
ORNSATIOrt DECLA ATIO
301 ROUGH PLUMBING
I thereb/yafical prr.".i of perjdrynaennhe fronowing deductions;
302 -.TUB & OR SHOWER
O 1 have and will maintain a cenificam or Conant m self-insnro for Wake, v
3 03 - ROUGH MECHANICAL
compensation, as provided for by section 3700 of the Labor code. for the
304 - ROUGH ELECTRICAL
perromunee of the work for which this permit is issued.
111 naJa and lothmamain Worker's CompsmationInsurance. as required by Section
3 05 - FRAME
3700 of lhe'Glwr Code, fim 'he performance of thewalk far which this permit is
3 0 6' - HOEDOWNS
Issued My Workers C.in,amouimn Insurance carrier and Policy number are
_._
_._ 307 . INSULATION..
a",at C- v ''i 1 -t. f ) `, t Pol' y No.. : , - „r
-r CERTTFICATION OF EXEMPTION FROM WORKERS
_ ..... ......... ._-
t!) }x.308 '; ; jSHEETRO,CKTIha t -LI ... .1;
" �cOMPCNSAnONINSURANCE'" - "-
3,09_EXTERI.OR.,"LATH'
- -- -,�-310 ._
t '. meed nm be completed if permit is r one hundred donors
'INTERIOR LATH
_
311 SCRATCH COAT
many er pen nna work for which m permit s issued I
t employ
6ha11 not emyloy onY person ;n any manner,w as to become subject to the Workers
313 - ROOF NAIL-
•7r t..i'(, : •• n ( r
t prcrr .D¢
Applicant
501
501 - FINAL ELECTRICAL ENERGY
rNOTICE TO APPLICANT If, rt k. gmac rtr[m of _Ept onymadimlld
-502 - FINALPLUMBING'-ENERGY
become subject o the Workers Compensation pmvo.u.fm Lahr Cade you must
forthwith comply with such provisions or this perms shat] be deemed revoked.
"
503 - FINAL MECHANICAL ENERGY
'••� v --''CONSTRUC[ION LEN DING AGENCY.' -
"InrebY'frno
- 504" =—FI"NAL BUILDING ENERGY• -'I.-:
- that th isoconstructionl ding agencyr Onimpoimana
of the work for which this pered,s Issued (Sec. 309], Civ. C(,
505 - FINAL ELECTRICAL) t c• -
..lindeeshhme �,s_„r:...;.:.., .a......_,,,•_. .._ ...,.•. ...
.IL...__._ 506--- GAS "TEST -- ---- -
n ci s Address .'
507 - FINAL PLUMB•INGI-''.t
1cenify thaj 1 have reed oris application ane state mat the above inrormation is
cotieci. 1 agree m comply with all city and county ordinances and nate laws relating
5 0 8 - FINAL MECHANICAL
m Wilding Construction, and hereby aumonm representatives ofthi, city to enter upon
the
509 - FINAL GRADE
above-mentioned property for inspection purposes.
(We) agree to save: indemnify an keep hmmless'the City 5f Cupertino against
510 - FINAL PLANNING
liabilities. judgmcnu, emu and expenses which may in any way ap[rue against said
City quenceo g ntin8 bf thi pe t
APPPI IS ST;,B,'
514 NVAZ WORKS
k LY., LNO -POINT'`
souRe E� ..///��5(((
1
Issued by: Date
sIg
a' our jr�rAPPI' C t cmr: �� le
Re -roofs
/ HAYARDOU ATERIALS DISCLOSURE'
Will the applicant flumebuilding occupant store or handlehauNous mammal
,_ Type,of Roof-,,,..
as d l d by the Cupen Municipal Cod Chapter9 13 arM th Health d Safety
-
Cod St 25532(x) -
❑r !iik
a "�” l
,.; - t
•roofs
-
W 11 Nc cam f t h Id g t a' n
All shall be tlispectedfpnor ti any roofing.matenal being installed, _
p qu pment s'wn'
.i r,o
it ie card ave roam t u d f ed by the B yAre A Q al ty Manage Management
If a roof is installed' without first obtaining an inspection, Pagree;to remove
O9nC - -
all new materials for inspection Applicant understands and will com 1 with
P_, Y.
- , t;,;"
all non -point source re ulations'- " ---'
g
tI" 1 Woo read the h urs s atonal r lremDas under Chapter 695'of
- 'v •
q Ihe
Celifomra Health & Safety Code Sections 25505:15533 and 25534. 1 understand that
if the bm Ing does not cunendy have a tenant, mat it is my responsibility to notify the
- -- - - - -
me
• ad, of me ie which mon bomn.pnw to i. uance f a Certificate of
-
._ ,i. ..
t i,
.: .. ..
Occup .,
"'" of -
..
Signature of Applicant
g. -. .. -.._ Date
All roof coverings to be Class "B" or -better'
owne ream .c m-.
..e:,., ...., . _ ...... ..-.. .. OFFICE. _._.. .. .. _ .
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