01100087 CITY ILDING DI ESiONNOPERMIT CONTRACTOR MORMATION:
BUILDING ADDRESS: PERMIT NO.
910 FERNGROVE DR 01100087
OWNER'S NAME: APPLICATION SUB DATE!
GERNER RICHARD E AND SHIRLEY 10/12/2001
1 PHONE: SANITARY NO. CONTROL NO.
O O ARCHITEC-DENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC
in<a L-I 1"_.I I= I
B,z LICENSED CONTRACTOR'S DECLARATION ]Ob De$Crl IIOn
5 Z=C 1 hereby affirm that 1 am IiceveJ undo provisions of Chapter 9(commencing I3
i Section force
) ITI ion 3of the Business and Profession.Cede.andmylicenu REPLACE BOILER.
Sms� in inn mine n l OXX
:swat 5 Lic.p
13 u U re/ Commc
p Q ARCHITECI"S DEC ATION
y I senders and my plans shall be used as public records
O O Licensed Professional
z OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Connector's Limmo,Law for the
C G following reason.(Section 7031.5.Business and Professions Code:Any city or county
Y D which reclaims a .too consaum,alter,improve,demolish,or repair any swcture $4850
u°6}3 m Dna tot nm,also req the pplicant for sari perdu.file a signed atam t
Uat h 1 sed purses no the pip ons of the Convector License Law(Chaps 9 r a , Valuation
11nn
(commencing_ nh Section,7M) f Division 3 of the Business d Professions Code) !,"1 r Ie�'���. )8,` a, }, t C.;v
or that he is exempt therefrom and the basis for the alleged exemption.Any violation
of Senian 70315 by any applicant(ora permit subjects the xpplicanuo a civil penalty
or not more than r hundred danara S5oo). PN i ." Occupancy Type
10 - ffR & WATER
❑1.downerof . aniny is an,einwideworts etheirsokle(Sevsauon,
will do the work,and the awcture is not intended or offeror for sale(Sec.70i4,
Business and Pmeslions Code:The Convenor's License Law docs not apply m an 301 - ROUGH pkjN SV6spections
u of property Who buildreace
s or improves thereon,and who dsuch work himself
or through his own employees.provided Nat such improvements are not intended or 302 - TUB & OR SHOWER
offered for We.If.however,die building or impmvement is sold within one year of - -
completion.theowner-builderwill have the burden of proving that he did not build or 502 — FINAL PLUMBING 'ENERGY
impra.mfar pwpoenfWe'). 506 — GAS TEST
- ❑I:asotherricevpmpeny,NUB.,irs,ardnwningwitCodensedcommcmrsm 507 - FINAL PLUMBING
caws the does
n (Se. to a Business and eny who
ills or The Contractor's '
License Low dams nut apply to an owner h property who builds or improves t an the O '
. andcm who contracts(w such projects wiN a conwnorts)licensed pursuant m the
El I a.exempt
ptmaarlaw.
O 1 am exempt under Sec. ,B&P C far reason � i,-,',� � l
0", ... Date /Q/
WORKERSCOMPENSATIONDECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will meinmin a Certificate of Consent to self-insum for Worker's
Compensation, ns provided for by Section 3700 of the tabor Code, for the
performance of he work for which this permit is issued.
OI hav nd will maintain Worker's Compensation Insurance,as required by Section
37W the Labor Coate,for he performance of the work for which has permit is
is .My Workers Compensation Inswana carrier and Policy number arc:, -
.L Policy Nor
CERTIRCATIO OF XEMPf10N FROM WORKERg', fie. Y-.. i '.} 4.?. t"iiH s{U
_. C PE SATION INSURANCE -' ' r
._..._....__.._... _... ..............-
action rte nm completed if the Permit is for one hundred dollars
(SI00)or or kir.) '
I ccrtay t i Aarmarte of the •.. •• ...• -
work fm wh' Nis remit is i.uued,
shall not empl any manna n t' met
Co numion of Cdifomia.Date c
cant
CE A ANT:If Compenng sation
is Certificate of Labor Code,you most
Z 2 becomes jell the W rs Compen r tkn provisions of the labor Code,you must
fomtiwi comply such provisions or N6 pertniuhall be dttmW invoked.
t "'' OBSTRUCTION LENDING AGENCY
1 h bywhi at Pere is issued Sea. lending agency Ibr Ne performance
W of a new fine whi this permit is issued(Sec.J097,Civ.CJ
Q' others Na
�.z nder's Address
.. :. .. . . . l . . .
'I certify that I have read this application and sate that the above information is
�iii correct.1 agree to comply with all city and county ordinances end slam law,relating
0 V to building cons0uctienl and hereby carbonic repmsenmtives ofthis city to enter upon
>. W that above-mentioned property for inspection► purposes..0. (We)agree to save;indemnify and keep harmless the City'of Cupertino against
Cnliabilai f judgari costs and expenses wh¢h mny in any way eccmac against said
V � City onsequcnc ERS gmming D thisLLC it.
'AP (CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
S "CEREGULXnON.S. , Issued by: it 9 Date
Re-roofs
ienanite-Will App�acare ce moor r pont score w hmWle harallous mmen
HAZARDO MATER4gLS DISCLOSURE Dam
'. "_wulNea fieaauno bnaain ma d Type of
as defined by the Cupertino unicipd C ' Chapter 9.12.and the Heahh and Safes
C _
midesection255J21a77'
❑Yes '�'� o'ONf..'i.' . . l 1 " . .1 s_, : i';�v'•'
,All.roofs.shall.be.inspected prior to any.roofing.material being installed.
Willthe app' antorfuture oilding eccupam use equipment or devices which' If a roof is installed without firsg t obtaining an-inspection; I agree to remove
caunharwdousa onmainanrs defined by Ne Bay Area Air Quality Man nt'
District' all new materials for inspection. Applicant understands and will comply with
El ❑No all non-point source regulations.
I rca4'Ne ardour maieri -quirements undd Chapter 695 0(the '
Calif. a edN& fiery Code,Sc s 25505.25533 and 25534. undcomm shad
if i ingd - of corneal veatenamn.thot it is my responsibility to notify the
ova a eft i a which must be at prior to issuance of a Cenificam of
Signature of Applicant Date
o real r;xed agent Date All roof coverings to be Class `B" or better
i
•" "' - OFFICE -