J 02090027 CITY OFCUPERTINO ` �` "y" - ' 9"' �`
p�Carer ace n gum ion:� �U P L I CA i�
BUILDING DIVISION PERMIT "�
BUILDING DDRESS: PERMIT NO.
1x490 FLORENCE DR DYCKMAN TERRY A AND BRENDA J 02090027
0WN6 M6: PERMIT ISSUE DATE
CKMAN TERRY A AND BRENDA 3 09/05/2002
III SANITARY NO. CONTROL NO.
ARCHITEC AINOINEER: BUILDING PERMIT INFO
B= ELECT PL 9 MECH
loZ' LICENSED CONTRACTORS DECLARATION Job Description
1�FFFF I Wmby&(firm that l am leaned under provision of Chapter 9(mmumming
b1 with Section 70110)or DlvWon 7 of the Business and Profession Code.and my licenmla
In full fame and effect.
uceewClw tie.0 WINDOW P N
Due TSDECL
ARCHITECTS DECLARATION
I understand my plan Mall W used as public accurate
a �a Lkrnad Pndcsdoml
b 3 OatIamBUILDER m Ce Corm ON
1 bercby.(arm that 1 1. exempt from the Coebacato e:Anse law for the
oo following resume. emits 7D31.5,Buaircat and Improve.
demolish,
Code:Any city structure unty RED,
$Pi: winch megcat n Peanlr m cornmeal.c.a@r.ImPmw,demolish,il e a repair any abudum
- E pdarmiuiunnau=.ntqulr°SIM&pplkulfarwchperm1uo01e&signdsummcm
4< Nash'IsliceluW puaurmatOte Pmovislon of tie Conuu:ateauammw law(Clupw9 Sy.FI, FIOOf Area Valuation
(commercials with Section 7000)M Division J of the Business and Profession&Cnde)or 15000
`a.. Nu he 1&exempt lhemfwm and the basis fa the alleged exemption.Any vlaha on of
Season 7071.5 by any appliesnl For a Permit wblem the applkant to a NMI Penalty ofp y Type
act mom this Ow hundred dollars($5005 3 � 0 0 ecuane
❑I,uownuof Nnpmpmy.mmyemployaswilhwguulltebwle rope^sedan,
winao the ends.and tite uructum tsaot intended w 0flead for suds,(Sec.7014.Business
and Profession Code:The CMATICmes Liana law does not apply at an owner or 101 — FOUNDS Ins pCCt10DS
property who Wildbarimpmwsthemon,and whodocsuch wort Mmwlraruu°ughhis 102 — PIERS
awnemployen,provided Ibstwch improvements sure not Intended oreffered far sue If.
lemover.the building or improvement isanld within on you afampletion.the owner. 103 — UFER
builder will how the burden of proving that h did not build or impmw far purp°w of 10 4 — REBAR
"to.).
❑1.as owner of the property.am exclusively connecting with Secured e°nuacton l0 105 - ANCHOR BOLTS
contract the prcjeet(Sec.7014,Basic.and Pmresiom Cade:)The Carbonates U. 106 — SEWER & WATER
ane Law does not apply w an owner of property who builds,or Improves Nercon,and,
who contacufor such prejecto with&ca^tnclor(t)licensed puannl an she Comauoh 202 - UNDERFLOOR PLUMBING
am Law.exempt under se
0 l 203 - UNDERFLOOR MECHANICAL
om e .B&PC fn thla anon
OwnerDECLARDam 204 - UNDERFLOOR FRAME
WORKERS COMPENSATIONATION 205 - UNDERFLOOR INSULATION
hereby amlm under penalty at pedmy aro or the Following extension: 301 — ROUGH PLUMBING
an ad will maintain a CeniOamoresnent m self-Iona for Wahe9 Comport. 302 — TUB & OR SHOWER
ut�lani uvphavi (ich No paemyitSxIs�anuas3T00 of the labor Code.fa the performance of the 303 - ROUGH MECHANICAL
❑1 how and will maintain Worker's Compensation Inurana,u required by section 304 — ROUGH ELECTRICAL
5700 of the labor Code. the,perfammuca of the work for which this permit ta banned. 305 — FRAME
My Worker's Compensation Insurance artier and Policy number am:
amen. PolicyNo.: 306 - HOLDOWNS
CERTIFICATES OF EXEMPTION FROM WORKERS' 307 - INSULATION
COMPENSATION INSURANCE
rlhtsteclirm need notheampleted lith Permit is farm hundred dollars(SIM) 308 - SHEETROCK
role&) 309 - EXTERIOR LATH
I amfy that In the performance of the work for which this Permit Is bound.I shall not 310 - INTERIOR LATH
employ any person Inany manxrm um became subject in Newarkea'CompenWoa ' 311 — SCRATCH COAT
Laws of California.Dau
Applin&al 313 - ROOF NAIL
NOf10E TO APPLICANT:.It.after making this Certificate of Exemption.you Mould
beeeme subject as the Worker's ComPewtion provisions of Ne labs Cake,you most 501 - FINAL ELECTRICAL ENERGY
.J O mr owuh amply with such provision or this permit hall be deemM invoked. S 02 — FINAL PLUMBING ENERGY
„Z„y CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
(—m I hereby clime Net Nem is a construction lending agency for the performance,of
a� the work far which this permit 4leaned(Sec.7097.Ch.C.) 504 - FINAL BUILDING ENERGY
wQ
I. 'a 505 - FINAL ELECTRICAL
a z Iendeet Addease
I anlfy that)haw read Niuppliation and Wk that um above informal.is 506 - GAS TEST
Oatael I agree to amply with all city sM county imbalances and sok Is"relating m5 7 - FINAL PLUMBING
O LrJ^ building construction.and hereby euthadm representatives of this City w enter upon the —
w glume-mentioned property ra instruction purpnee O - F I L ME C I CAL
gy (We)agree w saw.Indemnify end keep harmless the City of Cupertino spina O FI
H uebllWu,judgments.can and expense which may In any my uem°against Wd City
[)2 In conwgm^c°°f N°granting of thisIRrmit. S LIN
A APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT' Issued by: ate
SOURCE REGULATIONS.
Re-roofs 602 OOF PLYWOOD NAIL
Sipoua of ApplieHAZA arm Dam 3 - ROOF BATTENS
HAZARDOUS MATERIALS DISCLOSURE or
'Type of ROS
Wilby the
ertino uni buildings.Chamoomorand die Health and
604 - ROOF IN-PROGRESS
u Maned DY tin Cupertino Municipal Cade.Chapter 9.12,and W NesIN end Ss(ely
Coca.Section 255720)? All roofs shall be inspected prior to any roofing material being installed.
❑Yre ❑No
Will the applicant or future Wilding=upon[sew equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
"amnia air contwiaanu as donned by Ole Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes ❑No
I have and the huumon materials requirements under Chapter 6.95°(the Califon
nu Health&Safey Code,Seetimu 25505,75577 and!25534,1 unscrewed lhstifth Wilding
does not currently haw it lumbar,thin it Is my respmWbility in notify Ila°occupant m the
requirements which must be mel prior m Issuance or a CCNncalu of Occupancy. Signature Of Applicant Date
Owner or amhadred&gem Dale All roof coverings to be Class"B"or better