02100205 CITY OF CUPEB'I'INO
BUILDING DIVISION PERMIT CONTRACTORAINFORMATION
BU ILDING ADDRESS: DENISE FRANKLIN PERMIT NO.
21885 GARDENVIEW LA
WNER'S NAME: APPLICATION SUB DATE.
DENISE FRANKLIN 10/31/2002
LONE SANI'T'ARY NO, CON]ROI,NO,
ARCHI DICT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
WOO LICENSED CONTRd under
DECLARATION Job Description
u p I hereby affirm That 1 am fthicBd under nd Professions
of Chapter 9(commencing p
<zw with Section ndefec Division 3uf Jre Busirmss and Prn@ssiom CMc.and my license is
20 t2 in tome amerrc°. ADD 825 SQ. FR. rj� /�
License CIO far. {r�� /,LY'�
o4F, Dow Cnnaemor v� a ,
ARCHITECTS DECLARATION
as I understand my plans shall be used as public records AUG 2 8
x 2003 FLL4❑� Lkcawrd Pntlgasinnal
g OWNER-BUILDER DECLARATION
04 a y 1 hereby ullirm that l am exempt from the Contractor's License Law for the BUILDING ou 00 following reau n.(Section 7031.5.Business and Pnlesxions Code: B Any city or county
%m� which requires a permit to construct,alter,improve,demolish,or repair any structure
=ii prior tit its issuance,also sectsurs the applicant for such permit to file a signed Statement
< that he is paramour reronsoftheContracmisLicense Law(Chapter S Ft. Floor Area
f ❑ p Prov f p 9 $10 04IW®tion
Wm� (comu,is exemng ithhmion 71 and meDivisionaor n(the eged essand ProAnyviolaNe)or
3$ Nat he is exempt Therefrom and Ih'haze for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom man Tom hundred dollars(55I1p). or Occupancy Type
❑I,az owner of the property,or my employees with wages as Their sole compensation,
will do The work,and Ne su eture is not intended nr offered for sale(See 7040,Business —
and Pn,fcssionv Code:The Contractor's License Law does not apply m an owner of 102 — PIERS;eq3ulred Inspections
property who huilds or improves thereon,and who docs such work himselfor through his
own employers,provided that such improvements are not intended or offered for sale.If, 103 — UFER
however,the building or improvement is sold within one year of completion,the owner
budder will have the burden of proving that he dm not Naim purpose or improve for of 104 — REBAR
sale's' 105 — ANCHOR BOLTS
E)1,as owner of me properly,am exclusively contracting with licensed contractors of 106 — SEWER & WATER
consumer the project(Sec. Businesse:)0.Business and Professions CadThe Contractor's Li
eros law does not apply to an owner of property who builds or improves 8¢mon.and 202 — UNDERFLOOR PLUMBING
who contracts for such projects with a conaacmr(s)licensed pursuant to the Contractor's 203 — UNDERFLOOR MECHANICAL
ticcnm Law.
I am exempt under Sec. ,B&PC for oris maxon 204 — UNDERFLOOR FRAME
' °a Jy Lly 205 — UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATIO
'l hereby affirm under penalty of perjury one of the following declarations: 301 ROUGH PLUMBING
I have and will maintain a Cmmcme OfConsent Conseno self-insure far Workers Comport- 302 — TUB & OR SHOWER
o.4 n,as provided for by Section 370)of The Labor Code,for the pedommance of the 3 03 — ROUGH MECHANICAL
Thr which This pertnu is issued. 304 — ROUGH ELECTRICAL
I have and will maintain Worker's Compensation Insurance,as required by Section 305 — FRAME
3700 of me labor Code,far me performance of me work for which this permit is issued.
My worker's Compensation Insurance carrier and Policy number am: 306 — HOLDOWNS
came': Policy 307 — INSULATION
CERTIFICATE OF EXEMP0N FROM WORKERS
COMPENSATION INSURANCE 308 — SHEETROCK
(Thusect.on need not be comncred in be permit is Rhone hundred dollars(slap 309 — EXTERIOR LATH
orteify 310 — INTERIOR LATH
employ
that in the p to once of the work for which this permitrkers ed, Lena not
pinyany pccsun incl marjsMcomcsuhjcn to the Workers Compensation 311 — SCRATCH COAT
Law ofcmBor ' OJJ hh 313 — ROOF NAIL
P
mm �Itw.
- ETO
APPLICANT:If.after making this Cenificam of Exemption,you should 501 — FINAL ELECTRICAL ENERGY
become subject to the worker's Compensation provisions of the Lather Code.you most
p z forthwith Comply with such provisions Or this primit shall N deemed revoked. 502 — FINAL PLUMBING ENERGY
z'O CONSIRUCIIONLENDING AGENCY 503 — FINAL MECHANICAL ENERGY
F 1hereby anirmthin dorm isIconstmnionlending agency[or the Performance of 504 — FINAL BUILDING ENERGY
W ThCWrsNamewhich mispCTlllisissued(Scc.3(y17.Civ.CJ 505 — FINAL ELECTRICAL
0W O Leaders Namc
Lender's Address
5 z 506 — GAS TEST
V O 1 crnify that I have read This application and stale that The above immionalion is
Ocorrect.1 agree m comply with all city and county ordinances and state laws relating to 507 — FINAL PLUMBING
Vbuilding crnsruaion,and hercbyawhorimreprcmntativesofmiscity toenterupon the FINAL MECHAN CAL
aMrvc mcnBnmd 10 save for imnifyanpurines.
F 1 (Wil)agree ro save,indemnify and keen harmless The City of Cupertino against 0 9 FIN
N Iiabilides,judgmenrs,casts and expenses which may in any way acerin against said City C, A G
V z mctoor,ucnce of the gfanting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AIIIyyy NON-POINT Issued by:5 WWORKS Dale
SOUR R� ULATIONS. /1���'
S wreafApphra/veonaacmr —/l LJ Dae Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building owcupant store of handle hazardous material
az defined by the Cunonino Municipal Code,Chapter 9.12.and the Health and Safely
J.Q&'Section 25532(.)'
❑res -fl(N,i All roofs shall be inspected prior to any roofing material being installed.
Will me applicant Or future building occupantuse equipment ordevices which If a roof is installed without first obtaining an inspection, I agree to remove
Or hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
strict'!
❑Yes �No
I ham mad me hazardous materials requirements under Chapter 6.95 of the Califor-
niallcalm&Safety Cuk,Secuom 2SNI5.255J1 and 255W.1umtrsmnd that if dr Wilding
dogs wt currently have a tenant,mm it is my respmsibility m aolfy the ateupam of me
magi ¢which must W met prior m issuance of a Certificate of 0.cu soca.
�3 Signature of Applicant Dale
rrauthorimdagent Date All roof coverings to be Class "B" or better