02060159 OF
CI BUILD NG DIIVC'ISIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT N0.
2244l; rUPFRTTN0 RD 11909111 C;Q
OWNER'S NAME: APPLICATION SUB DATE
SUNNY VIEW LUTHERAN HOME 06/25/2002
(/ NE: SANITARY NO. CONTROL NO.
1
(a Q Zo ARCHITEC(ENGINEER: a BUILDING PERMIT INFO
kC BLDG ELECT PLUMB MECH
- b LICENSED CONTRACTOR'S DECLARATION
Z IherebyuRrmNeiIsmlicensedunderprovisions°fChapter9(commencing lob Description
=h witnSeaion]OW7olDivisionJofNeBuainessandProfeaxionsCode.anamylicenu
ie KITCHEN ADDITION (280 SQ. FT. )
S z ce full force end attar.License Class Coop
1g.,_
3 tractor
c. Date S DELLA
-a 0 ARCHITECTS DECLARATION r
I understand my glensmall be used vs public rtcordsLicensed ProfessionalOWNER-BUILDER DECLARATION
1 hereby aBlrtn Nat 1 am exempt from Ne Contractor's License Ww for the RE.
following means.(Section]031.5.Business and Professions Cc&:Any city°r county
which requirea pc n t c n t t alter, mprove,demolish or repair any strstructuree4uPnontstnuv¢<also reganes thepplkant forsuch permit to 0leeatgned sommt -5
3- thmheoUntriedp nimtolhepmvodnsofdmCommcmrsLicenseLowfChapter9 Sq-,Ft FloorAprear11 RR Valuation
mconcenCiDSwth Sado17000)Of Division 3 of the Business and Pnefessons Code) l y vl- ,iii irEi IIi,Y.`
or that he is exempt therefrom and the bests for the allejed insipuon Any v.l.,i.n 3 2 6 151'24 0'0 -
Of Smrion]031.5 by any applicant for a permit subjects,the applicant to a civil Penalty
:af not mart than.five hundred doll.($500). APN Number Occupancy Type
111,ax owner of the property.or my employees with wages as their sole compensation. 101 - FOUNDATION
-wul do the'work-and the structure is not intended or offered rot sale(sec.]nae. T02 — P=SRequired Inspections"
-'I
rAtuibeii and'Professions Coam:The Contractor's License law does not apply to an 9 p '
ow
ser of property Who builds or improves thereon,end who due,such work himself 103 - UFER
at through his own howevcr,t provided that such improvements ate Did in amended or -."1 04 - -- REBAR'
�nRFpletifor sale.IChowevcnthewildinge rden of provis sold tha within not year of -- ' :%v it.{r ... ",: •.r•
completion.the uwneowildcr will have the burden of proving that he did not wild or 105 — ANCHOR BOLTS
improve for Propose of sale.).
- — ---- --- - en. , mC.c_._. y- _. _ . . _ . . .._. ... ..106..-- .SEWER._&. WATER.
Duowner protea P(Sm.7,Om Business
and ProfeisinsCth icensThe°mntractm 'ttlL:.?G 2i.l'J/If l'd' •
202 - UNDERFLOOR PLUMBING
- = connruct the project ISa.7044,eusineu end Profession Codea The Contractor's �
License C.mrsinotapptymanois with
aproperty
contowhowirenmr] proven Merton, 203_ - UNDERFLOOR MECHANICAL
_'.. C. , end-who conwcts.forsuch.projms with a conwcwrisl.littnsed putwem a°.the.. .._._... ._. _
1. con a toraL«nR aw. .i 204 - UNDERFLOO FRAME:-
.
01 c lit nde c�_,,B&P C for this Rosen
205 - UNDERFLOOR INSULATION
' ERSC M
o `r OR' am ON DECLARATION 301 - ROUGH PLUMBING
_ 302 - TUB & OR SHOWER
'- i hereby ar0rm tinderpe of perjury one of the following decleratinns:-
�' 303 - ROUGH MECHANICAL
(y� + C I Compensation;
i n;willpro idein'v'Cby Secti m C.m3700 o to self-insure for Worker's
< j Compeunno,o: he provided-for by Section 3700 °t the Labor Code, for Ne 304 - ROUGH ELECTRICAL
ped°mon«or the work for when this perms is issued- 305 - FRAME
- - ❑1 have a5d will maintain Worker's Compensation Insurerice;m require'1 by Section
306 - HOEDOWNS
3]00'6(the labor Code for the pefformance of the work for which this permit is
iaiued My WorkOr'a Compenintmn In nonce carrier ad Polisy dumper,ate:,', ", -_.-307 INSULATION,--l-
,-.
NSULATION._-.,-. `' q - 31!08:!-"-,t,SHEETRE)CK ,o
CERTIFICATION OF EXEMPTION FROM.WORKERS. -
t COMPENSATION INSURANCE
�'rntn unlbn meet not be comPleiW if the permit is for orR hundred dollen 310,13:1 INTERIOR LATH rl•_ ;i..l ICS g.
ComOensetm'v d1mhft 11 60mea c�th�kf w6 ` . . 311 - SCRATCH COAT ..,-•• __-...-,._._._..��.R ..._,..-.,
i. /bac
amt permit norea:i 313 - ROOF NAILn d.
lif.
lc6;mnl I Ca t y '` ria to e6 `tmN w°k501 - FINAL ELECTRICAL ENERGY '
r 'L - 502" - FINAli PLUMBING- ENERGY -
ou Most
O forthwith Comply with such ismmorthisprmitshallbedeemWrtoked, 503 - FINAL MECHANICAL ENERGY
-"� becOmlherc�b eRh ANihoetHihemCis e�e°nsw oceda�'or„�r�NeW:... nadl _ . . 504 =--FINAL' BUILDING'ENERGY: '-,r .i. - -
g P Y
Y
Py P P<
^CONSTRUCTION LENDINGAOENCY t lf, '
y gc r x 505 - FINAL ELECTRICAL
dlhe work for hmh Nn perms n nsucd(Sec 309]Civ.C) .,
,w, c LaaebN w: GAS..T ST .. --
p Z LeitderxAdare, - 507 - FINALEPLUMBING ""
U.0 1 candy Nm I ha a Red Nrs appliceu n and nate thanhe ew<mfortnati nis 5 8 FINAL MECHANICAL
W �+ oriect I agree to comply nh VI ary and c umy oMbanca end xmte Iowa relin ng
OU ro bmlNngc AN[nOn ananMn)'08NOrIZe Rp2sC81811VG6°flM1aCtytOentCrp°n 09 - INAL E
the above-menboncdro n forms tion a u:.,_ 0 - INA L IN
y' y (We)agm o"spi've�iMemnifyu dkcep heRO4mlcss Ne City of Cupertino igainn
rI In liabilities,judg n s,costs utd expenses hich may in any way accrue against wad S 1 INA ORKS
U;.7a. City idconu send fNeg ting of thingp roti.
APPLTCA C 'DI R$�fA S`ANp W'IUL`COMPLYh'TTH ALL 'ON-POWTYe
Issued b Date
y
gnCwre,o/'APP,IieenVComtnaor'„:>-" "' ' ' =Dere" "' Re-roofs
HAlARDOUS MATERIALS DISCL�URE ': '
�'� Wdl Ne bpPllmbt o futM w Id10B occupwutare M Handle nezudon materiel Type of Roof - -
'm Eefmd by Ne Cupemn Mun npd Cede Ch Pt r 9 12 atW N Hevlth and Safety _ .l + +., 'i
Wk e
C ❑Ymoy5 32(4) V uy ° - T I +�' .'1" . t 1
r t Dip'. _All roofs shall be.mspected.prior.to.any roofing.material being installed.. _.. .. ..
Will the epplicenta (umre building occupant or,egaipmemordCACecwni°n If a roof is installed'Without first obtaining an inspection;I agpeeito remove
nu hai6ilo s am comm neon as defined by the Bey Arta A r Quality Management
mner7 .- _all new•materials for inspection. Applicant understands and will Comply with
r �9 oYa r all non-poini source regulations.
:flM1ave rtad the hazardous materials requirements Soder Chapter 6.95 of the t
CNffdrno Heal Safety Code.Seclions 25505,25533 and 25534.1 undemandthat
tlie'boil ding, t currently have a board;that it my responsibility to omify the
-
add - - - - -
'olcupaor N qui mems h must be mel prior to'issues.of a Certificate of
t °a pa"dy Signature of Applicant .. Date
/!-OZ
Date ... All roof coverings to be Class"B"or better
OFFICE._