00120102 CITY OF CUPERTINO ' -.,' .•
BUILDING DIVISION 'PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS. " PERMIT NO,
22117 CLEAR CREEK CT SCHRUMANN PLIJIYIBI.NG":AID FIF_ATING001 0102
OWNER'S NAME.: " - APPLICATION SUB DATE u
CLAUDIA LOHNS 1455 ;- LAURELWOOD RD 1.2/1. 5/2000
PHONE: ( - (408) 986=9044 , SANITARY NO. ; COM'ROL NO
O O ARCHITFCGENGINEER: BUILDING PERMIT INFO
RLDG ELECT. . ' PLUMB MUCH
- - 1 .1
ISI
LICENSED CONTRACTOR'S DECLARATION
z•8„4 - Job Description
z In bYfrnthtl ine licensed
' _d« p 'dChPa,1) nme
, dny
i w ng
'REMC141E,'ANP REPLACE ,FURNACE
3 F
Users clan C mracnn ,
TF.CP'S OF.CLA
��O� 1 undc¢mnd my plana shall he useAns public mmnLs- • � - -
.0 Licensed Free....ral ' •t - -,
o'Y OWNER-B UII.DBR DEALARAI'[ON _ k
.ed=m I Herehy affirm that I an exempt from the Cmllmcmr's License Law for the '
6 toll t, (S I 7031 5 Business d P re.: n.Code:A R 1y ati my - -
O wl h 9 P tt t t Ile,hor,re,s,dcourfilool repairny-I I e
pr t t, ,radua,alkone,ine,the pj1 tual fini croutl file a signed.statement -
555 -m°I he I parsuarat to the previouns of the Contractor s L Law clurpror 9. . S Ft "Floor Area -- '
aluation
or c e withS t Tann fU the li e. t i l i - q• '
of Section 1 p1 II f d Ih tbasis: ( th II g d pt A y iol i
.pe 'I nab)urc lha oppl u1 e u v'I penally
�� emnmroan5r eh�e�e dollars($saq APN Number Occupancy Type
❑La=ownaroftire li Carly.nni,yempinyca4withwaganasmatsdeatmpenv,dm,, 32E,iB0].F,: 00 ,
wl1 n m work,and r, :I Ire inn I t d 1 or offered r sale m apply to 41,. _ Required Inspections' ->
Iia' d P , n C d .Tb is I I ed e d I apply ec.7 o. _
owner rp petywn n"IB' .n --d n does. en kn” .re1r • 301. ROUGH PLUMBING k
or ilgh hs.,a rmph y e. Provided th t Such inprovini are not il nded or
offered lal Irh - e the bld s ,, inporwannant I,:l wide yecfof 31Z17. —. DOUGH MECFIA01.CAI_
- trun tln theoweehiiWerwill hasell IuMen of pm,itg that he ddtot bold or Y
impmnefor pnmenenfnla.). 30 — ROUGH ELECTRICAL
o L as uwaernI the p perry o lir lalling ,h licensed ctactors to 505 -- FINAL ELECTRICAL ..
" e 1 theP reject(S 7044 B e' d P -
n Code:)C :)Them
Coraatnr s .. .•
La 1 does ant ppiyt an` fpno,cey hoheird,in hopnerc,there,;n 507 — FINAL PLUMBING -
{ and no t ne for
h p . L with a t c r(s)licensed pursuant.m the -
cnnlracmrxLicenseLaw. - 508..x_ FINAL: MECHANICAL
❑I am exempt tinder Sea.- ,B&P C for this raaann `
Owner Data e.
WORKER'S COMPENSATIONDECLARATION -
Iherebyaffirmunderpenaltyof perjury npe of the following declarations:. - , -
El 1 have and will maintain a Cenitiator or Cnoent to self-insure for Worker's ' - • "
G, K I p d d I f by Sc t 1900 Ih 1 b Corefor Inn -
pefforri ofthwork or whichLos rp t is issued. -
1:11 fiewearid ill nomfor,W kn',Compensation Insurance, rcgtf d by Se tin � t -
1700 of the Labor Code for the Derfor rine of the work for which this permit s - ,
iayued.. Workers Cat nsvtion lnsu.nurcrtter and Policy mmh arc
-
Carr /0 �/$fyN
CERTIFICATION OF EXF,MI''I ION PROMRK
COMI'P.NSA'I ION INSURANCE .
(This xrefna need nen he cnmplelyd if the pernnil is for one hundred dollars - 1
r
SHIP)it,lass)
1efrynhl" the wfoas eofn work for 1 hth p 't's issued,I
'hall I-n empingany person in anys
n ., arm heat to..byet to the Wnrkerx'
Cnmpanration latera of California.Data '
Applicant r a•
NOTICPTOAIPLICANhIf It ukl g❑ Cu tit oto of Rxemption you dhould - "
hpe' bj n the W k C p ns.1 p .ofdcl.ahnr Coda ym nun - f•
0 6N "tb olnply willh p is or the p io shall be decanted cooked. , -
'F ZI CONSTRUCTION LENDING AGENCY b
I hereby alum Ih l Ih re': -t f dit b age y f theounce
perfin
nay of the work for which this Penn!,is ss1 ed(See 3097Civ.C)
Qn.A Lender'.stab. • ` ,
Z' Lend Address _ .
V 0 I centily that lhavicead lhsxppl I d state that the hove arloninnion': -
W icy or 11 agree n-' -,ply with all city and ationly nolanninces and.t1 Ifnb r
V d,,buldne,e nn f n and hereby aum,r'' pre. t1 I this ctymener upon .,1'
the h toad p p 1y for inspect I R ex - -
E. It
(W)oi1 d nify andk p hati1ho Cly i Ca,parrihna,inest .'
h liah I ai, ad,onani cast, p h y any ay against said �
V City q rlthe b nang nuil.
AP ICA UNDERSTAN LL COMPLY WITH ALLN PINTC.�� �� I"�lr—vy•,
sr 'con n�/)# .Issued by: : Date (((
sig rAppl can ommcmr � - Re-roofs '
HAZARDOUS MAI LRIALS DISCLOSURE °Will Ificapplickent or f t ra building occupant store or handle haeabl ns roe rial Type of Roof: 'le
as defined by the Cupertino Municipal Code Chapter 9.12,and the Health and Safety' - - -
Code,Section 25532(a)^ t
❑Yea-' ysler ' IAlfroofs shall be,inspected prior to any roofing'roaterial being installed.
W1II nh Fru. f t •building ott,p not 1 neegn p I desire'
h.A '.
P If a roof is installed without first obtaining an inspection, I agree to.remove`
• umnh A cam 'n t. tv defined by the Bay AmoAir Q Quality Manag m ,
Disarm?, all new,materials for inspection. 'Applicant'understands and will comply with
°re � I °J all`non-point source regulations.
.. I n re td tha h e d ¢ria):requirearnars under Chiiincr 695 of they _
California Learn&Silly, c,5cirtions 25505 25533 and 25534 1 understand that
buldingatwn'n - tlyl mea thtl' yre.p 'b'I'nyn olifylha,
n nr the reglr b' htech t l n,is. f C 'Item o[
tt`y — - Signature of Applicant +;Date
- All,roof coverings to be Class "B!',or better
On audiort : -� •
nwc
» OFFICE` M1f ,