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CONTRAGTQR FO,RMA"CI(lN,
BUILDING DIVISION PERT
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,5 rn1R. r.i tis tE.'
BUILDING ADDRESS:
PERMR NO.
21076 GRENOLA DR
NEWS NAME:
PERMIT ISSUE DATE
TAFT & NICOLE COLEMAN
04/05/2006
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
o
Job Description
1 hereby N
by affirm et i am licensed under provisions of Chapter 9 (mo mencing'
with Section 7M) of Division 3 ofthe Business and Professions Com.and my license is
BATHROOM REMODEL WITH SHOWER PAN AND NEW VANITY
I. full fame and cfrm
Limmue Class uL.e
AND TOILET. NO STRUCTURAL CHANGES TO LOAD BEARI
Dale ContractorARCHITECTS
WALLS.
®�Nll'���
I understand my plans atolll be used aDECLARATION
p A is records
I
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby alarm that 1 am exempt from for Commctors License Law for the
following reason. (Section 703 I5. Business and Profnslions Cole: Any city or county
I 006
ow L 2
which requires a permit to construct, a@e Improve, demulish, or ¢pair any swetum
prior to its Issuance, also requires the applicant for such permit to rile a signed smument
for he is licensed innocent to the provisions of the Connector's License La.(Chepw, 9
Sq. Ft. Floor Area
ua[i�p�350
(commcncing with Section 7000) of Division 3 of the Business and Professions Cmle) or
4
that le u asmpt tM�efrom and the bsals for ue alleged exemption. Any violation of
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Secdon 70315 by any applicant for a permit objects the applicant to a civil penalty of
APN Number
c ane y if`'s,pe
nut come than five hundred dollar (5500).
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D1.umnerofthepmpwy,mmymploycuwlNvnguuuuirmtcwmpemadon,
326 8
Required Inspections
wi0 dathetori. and esu fmsale(Sec. to ad. BuMms
eft License Lew urea not apply If an awmr
he CommutersLicenses ave do
and Professions Cade: The
property who buildsviimproves thereon,and wM datesuch work b is
improved do
fedfwage his
improvemantsan, not creamedfor ale. If,
mm employee,ping
ar.fdmaRercd
orithusorae
builds' Nebuildinghe Improvementg cold
didoneyearofrompleufrtheowner-
builder will Mw the burdan of proving out M did ml bWld at Improve for purpose of
�sale.). '
WTD ss oa'nu of the property, am exelusively contracting with licensed rontnemn to
construct the project (See. 7044, Business ted Profusions Cade) The Contractor's U.
came Law does but apply to an cams of property who builds m improve thereon. and
'
who contracts for such projects with a cor mmoKU licensed pursuant to the Contractor's
Wcmve W.
ofam eamptund"ff& ,B&PCforthismuon
r / Date
.
WORKER 'SCOMPENSATIOND LACTATION
I hereby affirm under pcnsity of perjury one of the following declarations:
❑ I have and will maintain • CWr=mofCoesent a self-im= fm WohefaCmpen-
sation, u provided for by Section 3700 of the Labor Cade. for the performance of the
work for which this permit is issued
SANITARY
❑ 1 have and will maintain Workers Compensation Insurance, As required by Section
37o0 office labor Code, for the performance of the work fm which this permit is Issued.
My Workerance 's Compensation Inmrcarrier and Polity number am:
Cartier. Polley No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlssectiot need not hccomplemd lithe permit is fm one hundred dollam(S100)
r
or leas.)
I certify Not in Ne pc rmance of tie work for which this permit 4 isrmd, I shall not
I any'permrtln�y mannt�ao e®k ttothe WorlotWCompensNan
Laws o(CtliforrmmyiOD ✓
AeeRkant
PPLICANT. If, after making this Certificate of Exemption, you should
Mb
Ybjeft b the Workers Compensation provisions of the Labor Code, you most
forthwith comply with such provision or this Permit shall he deemed revoked,
CONSTRUCTION LENDING AGENCY
I hereby alarm that them Is a construction lending aimmY for Ice performamo of
thework for which this permit is issued (Sm. 3M. Civ. C.)
Lender's Name
-
Lendeh Address
1 cerdly that 1 have rad this application and sum that the above information is
'
conctt 1 agree to comply with all city and county ordinances and sum laws statin, to
'
building construction, And hereby aemorim mpmscmatiros of this city to emr upon the
above-mentioned property for inspection purports.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
Ilabilidm.judgmenw,canstedexpenseswhich may In anywaysameaga etseed City
APPLICA eonseq N1, of the granting of Ids panic
DERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOUR UL TIONS _
Re -roofs
Type of Roof ,
Si um of Applicam/Contractor Dam
HAZARDOUS MATERIALS DISCLOSURE
Will dm applicant or fuurc building occupant some orbandle herardous material
as defined by the Combine Municipal Cade, Chapter 9.11, and the Health and Safety
Section 25532(e)± yy
Oyu �Sl nu
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or dcvim which
emit haysrdous air contaminants As defined by the Bay Arta Air Quality Management
all new materials for inspection.
District?
❑ye,
1 have mad the heartless materials requirements under Chapter 6.95 of the Califor.
nia Hulth&Safety Cah,Scctian25505,25533e 255M.lundemmiMthatiffe building
docs not curmntly ham a tenant, mat It is my responsibility to redly the occupant of the
reyulrtm lehmet, tat met prior to issuance ofaCcniMMOf " y-
Signature of Applicant Date
Y
All roof coverings to be Class "B" or better
caner or Authorized agent Date