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02100182 CITY OF CUPER'1'INO "" BUILDING DIVISION PERMIT CONTRACTOR"INFORMATION: as BuJJD&490aEsFLORENCE DR DYCKMAN TERRY A AND BREND PFOlo"'N92100182 15Y!12q MIIAN TERRY A AND BRENDA S APPLICAT!PnsS B"N2002 PHONE: SANITARY NO./ / CONTROL NO, ARCHITECfIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 f00 LICENSED CONTRACTOR'S DECLARATION "^7 F I hereby af0rtn that I em licensed under provisions of Chapter Y(commencing �/� }T�f �T�sr�2�Tlp with Section 7lXYBnf Division 3 ofthe Business and Professions Colic,and my license is KI CHEN ,REM - " •"'ll� FOin in full Imen and olfoer. ZOga License Claxs Lic.A i OZ� Dale Contractor ^^- F� ARCHI TSDECLAR ATION 1 understand WEnd my plans used as public records O�V F Licensed Prnfcssional Be C OWNER-BUILDER DECLARATION y 1 hereby affirm Thal 1 am exempt from the Contractor's License Law lin the r uhf a O following maxua(Section 71131.5.Business and Professions Code:Any city nr county $(< which requires a permit to conslrun,alter,improve,demolish,or mono any structure prior m its issuance,also requires the applicant for such permit to file a signed summon, €� that he is focused pursuanuo the provisions of the ComracnMS License Law(Chapter 9 3S46136FE15dn A@0 Valuation $ (commencing with Section?(XXB Of Division 3 of the Business and Professions Code)or Out he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of 1UAPNNURqPAT1UN Occupancy Type not more than five hundred doll..($500). 102 — PIERS ❑ I,as owner of On pmpeny.or my employees with wages As their sole compensation, Will do the work.And the swclure is not intended or offered for sale(Sec.701,4,Business UFER Add Proficubbv Code:The Contractor's License Law does not apply tu an owner of 104 - REBAR Required Inspections property who builds of improves thereon,and who doessuch work himself or,h.ugh his own employees.provided Nat such improvements Are not intended or offered for sale.If. 105 — ANCHOR BOLTS however,the building or improvement is mid within one year of completion,the owner. lO6 — SEWER & WATER builder will ban the burden of proving that he did not build lir improve for purpose of sala.). 202 - UNDERFLOOR PLUMBING 01,as owner of the property,am exclusively contracting with licensed contmeton to 203 - UNDERFLOOR MECHANICAL construct the project(Sec.70P,4,Business and Professions Code:)The Contractor's Li- wine Law does not apply to an owner of property who Wilds or improves Oemon.and, 204 - UNDERFLOOR FRAME who connotes for such prejecu with a conuacmrbs)ficeved Punuanto the Comncmra owe Law. 205 — UNDERFLOOR INSULATION l em eacm tun Sec. B&PCfor srto n p 301 - ROUGH PLUMBING �`r 'SCOMPENSIf�—COMPENSATION DE rimQN� 302 - TUB & OR SHOWER if 303 - ROUGH MECHANICAL Ihercbyaffirmunder penalty of perjury one ofib uunwingdmlahationa: 304 — ROUGH ELECTRICAL ❑l have and will maintain a Centfcate of Consent to self-insure for Wohels Compen- 3OS — FRAME cation,as provided for by Section 37M of dm Labor Code,for the performance of the work for which be permit is issued. 306 — HOLDOWNS ❑I have and will maintain Workcer Compensation Insurance,in required by Section 3 07 - INSULATION 3700 of the Labor Code.for the performance of the work for which this Permit is issued. My Worker's Compensation Insurance carrier end Policy number art: 308 - SHEETROCK Carrier: Policy No.: 309 - EXTERIOR LATH CERTIFICATECOMPENSATION INSURANCE ORKERS' 310 — INTERIOR LATH maiasectionnand noikeompletedi(the permtlisfnronehundreddollunrISIgs) 311 - SCRATCH COAT "rI`ss) 313 - ROOF NAIL cc' this in the pppppp���'torrrryryry ccofthewor forwhich s permit isissued,l shall not 501 - FINAL ELECTRICAL ENERGY cmpinyany Pcrsnof her + yync.euli�+Jhe Werkcrs'Cnmperimum. Laws of tiifnmia. a / 502 - FINAL PLUMBING ENERGY Ap N TOAPPLI NTeraCommakingNisCcninsofthe aborode,youhmuld 503 - FINAL MECHANICAL ENERGY become h comp(to the Worker provisions or thisPeron Permit shai of theLaborcaked. must 504 - FINAL BUILDING ENERGY OO forthwith comply with such provisions or this Permit shallMdpemed revoked. CONSTRUCTION LENDING AGENCY 505 - FINAL ELECTRICAL [—i .yi I hereby Off,,.Nat there is a construction lending agency for the Performance Of 506 - GAS TEST C' > OcWork for Which box permiIisissued(See.3VJ7,Co,C.) Lender's Nater. 507 - FINAL PLUMBING f11 a z Lcnder'sAddress 508 - FINAL MECHANICAL U O 1 certify that 1 have read Nis application and smm that the above information is 509 - FINAL GRADE correct.I eprcc to comply with all city and county ordinances and smote laws relating Io pU building construction,and hereby authonmrepresentatives ofhis city tochief Poll tire 5 FINAL PLANNING above-mentioned m rl for inspection purposes. IA P P y " PeeCity14 FIN LIC W RKS L>r liabilities, save,indemnify And harmlessthe re Against City to inconsequ consequence of the COWS And Of thispswhtch may in any way e¢mc against uid City V 7 A APPLICANT of the grantingRSTAN of this permit, APPLICANT UN RSTAN SAND WILL COMPLY WI'f}ky,L NON POINT Issued by: Date SOURCE RCG ION J Re-roofs nature of icanVComractor Data HATARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building Occupant store or handle hamrdous material v defined by IM1c Cupertino Municipal COJe.Chapter 9.12,and the Health and Safety de.Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed. ❑Yes u Will the applicant or fm re building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection, 1 agree to remove emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District/ Yea Hit read dm hamNoua mamriala rtquirtmentsunJer Chapmr fi95 of Ne Calilnr nia HCalth A Safely Coda,Sock.25505,25533 and 25530.1 understand thatifthe building Iona not curremly ve a mnanl, itis my responsibility m notify the rccuPan,of the requirement, must hem or toiaaaaneenfaCenificamN ey Signature of Applicant Date owner or au rlmda em am All roof coverings to be Class"B" or better