02060063 NO
CI euDNGDPEROu N PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10294 DEMPSTER AV 02060063
'NER'S NAME: APPLICATION SUB DATE
PANS VAN DEN CROMMENACKER 06/11/2002
PHONE: SANITARY NO. CONTROL NO.
ceO ARCHITECY'ENGINEER: BUILDING PERMIT INFO
m C BLDG ELECT PLUMB MECH
a
LICENSED CONTRACTOR'S DECLARATION
v z I heresy Rnn thin 1 am licenxa under0 ,'inions of Chapter 9(commencing Job Description
iy_o
:_t, w;ms«e°nn 1urDivision3mnneBusme. arrmdssmnscnde.anatBy.)men.e BATHROOM REMODEL
s in full far a effect. // c r��r� _�
z�a License Cla � Li�cu.ta@��{,b�7wWC181 �ep Q Da ®
LL te —I CDI;GlS4RATIDN Qreneke 7
ARCHITECT'S DEC�1
a 1 undersand my plans sM1all be used as public records
O pE P
rc]ZOO Licensed Prorfessional 1 2002
OWNER-BUILDER DECLARATION
nxs R a I hereby affirm that I an exempt from the Connector a License Law fm the
e < following reason.(Section 7031.5,Bu lmces and Professions Code:Any city or county BU1L,D11VG $17000
E p which requires pe p p ystructure
i3= Anon t s once also q sd¢aVNcatf nPermited fl sgcd ttemem
permit consumer, te demolish,o repair
ma he licensed pursuant t m pin of the C t t 'sl La (Charter 9 $$pp ,,pp7� tt Valuation
(comm tic 8 h5 t 70001 fD" 3 fm Business dP f Code) Q�'•� t �;3 Zb' ;U{7Zr �d'
or shot he is exempt mem r un and the bass for the alleged exemption.Any violation `
of Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty
.of of mehinfive hundred doR.(s500). 101AP— DATION Occupancy Type
01,as owner ofine property,or my emph,,n,with wages as their ole compcmmion. _ PTPPq
1111 eco the work,and he srucmre,s not intended or offered for sale ISce.7(44,
Business and Professions Code:The Contractor's License Law does not apply to an 103 - UFER Required Inspections' ^ '
owner of propcny Who builds or improvex thereon,and who does such work himself
of through his own amply= pro ded th t n p...current,.,a at intended of 104 - REBAR
.offered for sale If,howevu,the building 6r improvement-is sold within one year of —_
completion,the owner builder eLhave beburden ofprowngthat hedid nor build or 105 - ANCHOR BOLTS ,.
improve for purpose of sale.). 106 - SEWER & WATER
i pLeswnerrof.eepmper70".BdinessandP,ely ami romssions odemoad:)ne onterrsro 202 UNDERFLOOR PLUMBING �• :. .',
construct the project(Sec,7004,an irwom of of and Property nobs ild,or Thc,rime o.,
adwhense Lammumortapply oosucmrjectswthpruperywiml)iivemodpamomo so 203 — UNDERFLOOR MECHANICAL''
cnci n�enaurLawurn projects with a.eumm mqs)ban dpursuant m me- - " - - -2 04 — UNDERFLOOR' FRAME -
❑lamexempt order See. ,e&PC for this reason 205 — UNDERFLOOR' INSUEATION
"a" Da1e 301 — ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION 302 — TUB & OR SHOWER
I hereby arrm,unser penanr of perjury one a me following aeaaatmns: 303 - ROUGH MECHANICAL
❑ I have and wiu maintain a Cerliume of Consent to self-insure for workers 304 — ROUGH ELECTRICAL
. compensation, as provided for by Section 3700 or the Labor Code, for the 305 — FRAME
Performance of the work for which this permit is issued.
❑I have and will mamtam Worker s Compensation Insmanee,as required by section 3 06 - HOLDOWNS
sued.M`Wororicr:Compensation for anion Ins�r ace carrier and Policy wmeb moa permit is 3 0 7 - INSULATION
My pfor t y mbcrhis
ljTen ' tireel'r°fe <//n' y �� 30H _= " SHEETROCK ._.
.. .
CERTIFICATION OF E%F,M N FRO ORKI. . + <3 0 9- EXTERIOR s`,LATH'
., COMPENSATION INSURANCE" '',_ -- _ __
-310-=--INTERIOR--LATH- - -- -- -
(This section need not be completed if the permit is for one hundred dollars _.
(a100)°nes) , 311 — SCRATCH COAT
1
313" - ROOF -NAI
Wiry in.,'n m p<rr " ane of the for which m' Permit suee,1
mase not employ any Person in any manner s°as to become subject to the workers' 501 — FINAL ELECTRI CAD 1'ENERGY
Compemm,nm laws or California.Dar` 502 — "FINAL-
NOTICApruirint. PLUMBING. ENERGY.. .._. .
NOTICE TO APPLICANT A after Compensation
this Cisions Of
Lalvartiode,you most
503 — FINAL MECHANICAL ENERGY
Z become subjemmthe Worker's Compcnsmion provision..of the Labor Code,you must
ZO fonbwidlcomplywith inch Provisions urthis pie rano shall bedeemed revoked. 504 -- FINAL BUILDING ENERGS'..._ ..
0 """ CONSTRUCTION LENDING AGENCY
F'' Ihcrcbyarfmmthat there isacdnsuerimnleading aget,for the pcif o.mance' 505 — FINAL ELECTRICAL "
�t r ofthn work for which t-Name
` LL .. ..
u
D Z LepaersAmnrx1 507 — FINAL PLUMBING
U-O i cenify mat 1 have read cot,appliemiun sad slam mat me above information is 508 — FINAL MECHANICAL'
comot.1 agree to 111.11,with all city end county ordinances and sed a laws relming 509 - FINAL GRADE
O U to building constrvn;on:and herebyauboriu representatives of this city to enter upon
y.W I the above.menanpedpropenyfor inspection purposes. 510 - FINAL PLANNING
. al
1FG ",judgmemscostandeipearad seskeeph may i nthe Ciayaerm,aaistn. said
z City in cojudgments,costs ran expenses of this
which may in any way aeeme against aa;e 514 - FINAL PUB I C WORKS / O
U ^ City in consequence of RS granting D avis permit. J
APPLICANT 'NDERS 'DS DwILLC .. LY WITH ALL NON-POI 3'
SOURCE .:,LAT Issued by: Date
sere 'A
pplicnmo on racmr Date Re-roofs /
HAZARDOUS MATF,RIALS DISCLOSURE
ern me applicant m mm,e nadamg ucatwnt score or Handle namre6us material _ ..Type of Roof _ _._ ......
,def ed"'the
y th CLper o Mu <p 1 Code Chapter 9,12.and he Health and Safety
Inde s i 2553 (a)' -TI6/.N -. ,v
°Y All roofs shall be inspected prior to any roofing material being installed.
.Will m applicant i r t bdfirml vat use aAiequipment orae _s emet If a roof is installed without first obtaining an inspection,`I agree to remove
lh Willi contaminants defncdb)meBay AaAi QalgM -agement
Iq °iina7 all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
1 have read the hawdous materials rcgmmments under Chapter 6.95 of the
California Health&Safety Code Seminal 25505,25533 end 25534.1 understand that
tithe budding does not currently have a tenant,that it is my responsibility to notify the
ovenpam of the requir men¢which must W met prior to issuance of a Certificate of
:-
_ Signature of Applicant_ Date
- e °rout unwed ag=tit - ' '
*v All roof coverings to be Class "B" or better
OFFICE _
CITY OF CUPERTINO '
BUILDING DIVISION PERW CONTR'AtTOR INFORN01ON:
BUILDING ADDRESS:
PERMIT NO,
10294 DEMPSTER AV 02060063
OWNER'S NAME: APPLICATION SUB DATE
IS HANS VAN DEN CROMMENACKER 06/11/2002
HONE: SANITARY NO. CONTROL NO.
e m z ARCHITECT/ENGINEER:u O O BUB-DWG PERMIT INFO
BLDG ELECT PLUMB MECH
mad
i LICENSED CONTRACTOR'S Made DECLARATION Job Description
j v 1 hereby aRmn mat ISM licensed under p visions of Chapter 9(commencing p
=CQ wimscction] )ofDivision3oftheBusine 'a pmm,,0.n,coa . any-Been. BATHROOM REMODEL
m 3 is in full for d effect. -2 G s
to6U License Cla{{ V Lice 4J �ZS
Date G—! Coowwl�tpr
t3L LLO
dcARCHITECT'SDFyX4RAm11srnc•lf ,7 9/�
8 g 1 unrsmnd my plans shall her used «cmod ti
d as public ords
p O Licenser,Professional
xoff O\VNER-
gU1LDER DECLARATION
'
u— 1 hereby affirm that 1 am exempt from he Condw or's License Law Mime
h i a following reader,(Section]0315,Business end Professions Code:Am,city w county (.
C yl FIC wnlch requires a permit to eonsWct,alter.ImpNvc,demolish,or mpa V any stmeNR
170000
a 3
mind its industrial alw equionds,applicant for such permit to filezxignednoemem
Nm he is licensed pursuant tome pr,lims of the Contrition's License law(Chapter 9
(commencing with Section 7")of Division Sof the Business and Professions Cede) 3 �- ie r-Rf6' Valuation
or that he is exempt thcmfmm and the basis for the alleged exemption.Any violation
of Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not mart than five hundred donor:($51)[1). 102,pN 4'13ftDATION Occupancy Type
El 1,as owner of the proparty,or my employees wlm wages as their sole compensation, _
will do the work,and she structure is not intended or offered for Sale(Sec.7014,
Business and Professions Code:The Control License Law does not apply to an 103 - UFER Required Inspections
owner of property Who builds or improves hereon,and who coal such work himself
or through his own employees.provided that such improvements we not intended or 104 — REBAR _
offered for Sale.If.however.the building or improvement is sold within one year of 105 - ANCHOR BOLTS
completion,me owner-builder will have the burden of proving that he did not build or
improve to,purpoaeofsalea. 106 - SEWER & WATER
LI 1.as owner of me propeny,am exclusively contracting with licensed contractors to 202 - UNDERFLOOR PLUMBING
coal he project(Sea 704a,Business and Professions CWc:)The Contractor's
Lima.Law deals waapply 10SomnerofPropel IsinWilds orimports.drartoa. 203 - UNDERFLOOR MECHANICAL
.ad who comment for such pool with a contractors)licensed pursuant to the
Cranial license Law. 204 — UNDERFLOOR FRAME -
01amexempt under See, ,B&PC for this reason 205 — UNDERFLOOR INSULATION
Owner Date 301 — ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION
Ihmabyafrrt uneven peamty of perjary etre°f me fnnnwing deelaratienn: 302 - TUB & OR SHOWER
303 - ROUGH MECHANICAL
❑ 1 have am will maintain a Certificate of Conant m self-insure for worker's 3 04 — ROUGH ELECTRICAL
pI mtesn a of the wo�ktfordwh chbhisgpe ttm°i�is s�etir the Labor enae, for We
305 _ FRAME
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3 06 — HOLDOWNS
37W of the Labor Code,for the performance of the work for which this permit is
island.My workers Compensation InsnnneeMurder andPmicynumber art: 307 - INSULATION
fir l Tiy-rr� toed Polievta�1 /4 rhe/L,/q �� 308 . = SHEETROCK '
CERTIFICATION OF EXEMWd9NFRF�0.41aS'. 309 — EXTERIOR''LATH'
._ COMPENSATION INSURANCE
_....310. __ 'INTERIOR- LATH. . .. .
(This union need not be completed If me permit is for one hundrtc dollars
(sIW)mleda.) 311 — SCRATCH COAT
I codify that in me of the work for which his permit is issued,I 313 - ROOF NAIL -
shall not employ any person in any Wenner so as to became subject so the worked Laws of California. 501 — FINAL ELECTRICAL ENERGY
Applimpensation alifornia.Date
NOTIC°` 502 — FINAL PLUMBING ENERGY
NOTICE TOct10 he AM1T:IL Co ma... thiso Sort,compete Exemption you 503 — FINAL MECHANICAL ENERGY
Z becom<wbj¢tto she Worker's Compensnton provisions of the Labor Code,you mom
Zp forthwith comply with such provisions tor miapami"Itaubedrameirevokei. 504 — FINAL BUILDING ENERGY.
CONSemisac0NLENDING AGENCY 505 — FINAL ELECTRICAL
a ' thereby which
that inert i is csued(Sl lendingagency for me performance
ofn work
Addrewhichhispermitisissued(Sec.309].Civ.CJ 506 - GAS TEST n
yG LcndeYS Name 507 — FINAL PLUMBING
Z Lcndcr's Address '
I sell that I base read this application and.,are Wt the above information is 508 — FINAL MECHANI CAL
0 Ftotal 1 agree to comply with all city and county ordinances and nate laws relating 509 — FINAL GRADE
U to building constmnion,and hereby authod«representatives ofthis city[center upon
y w he above-men0onedprperry for me,all purposes. 510 — FINAL PLANNING
A. (We)-Fee o I animal and mle
keep harss the City of Cupertino against
�+ tin liabilities,judgments,costs and expenses which may in any way accrue against said 514 — FINAL PUB I C WORKS
V rZ. City in consequence of the granting°f bar mut. n O�
APPLICANT My 'DS WILL LV WITH ALL NON PO
SOURCE LAT s. Issued by: Date
aux pphuentaLturn aetor Data Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furnace building occupant n=or hal le haL(dm6 material Type of Roof
u defined by the Cupcnio M
nuniny al CodC
e, hapter 9.12.and me Hulm end Safety
Code,Section 25532(a)?
oxen All roofs shall be inspected prior to any roofing materia] being installed.
PonW llthc applicant future building by Me may At use es AirQnt ordevicesMar agarwhich If a roof is installed without first obtaining an inspection, I agree to remove
hessrdous air comaminents as defined by me Bay Area Ara Quality Management
"m"] all new materials for inspection. Applicant understands and will comply with
�V t,
❑Yes l�Nn all non-point source regulations.
1 have read me Safforely
Code. materials«q,25533ta under 4,1 Chapter 6.95 of the
California Health&Safcty Coda Sections ant.that
t it
and 25534.1 understand that
if me ost o t docs not meatsmoral have a st W that is is to responsibility to notify the
occupant of the requirements which nun be ion prior m issuance of a Cenifica¢of
Oaupan
6..f r b Signature of Applicant Date
n man norm age^' me All roof coverings to be Class "B"or better
OFFICE