00050149 CITY OF CUPERTINO
BUILDING DIVISION PERMIT. CONTRACTOR INFORMATION:
RUILDING ADDRESS: 't PERMIT N0050149
10660 JOHANSEN
OWNER'S NAMG: - \" APPLICAI i,A'TP .
`E LDRIDGE, 'DONALD/MAVIS i Ycc/2Q100
I.
for ONE: - ' SANITARY NO. CONTROL NO.-
o
ARCI "ECUENGINHEdW. • - I'f - • BUILDING PERMITINTO
�•• a ' EBecr Pwmn MECH
LDc
LICIiNSEO CONTRACTOR DI!CLARAPION
z 5 4 0 1 herch fort,mat l am Eccnsed render t Charter 9 wrannuentin Job Description 'n -
pZ—p . yn Prnvianns o' Per g �a _
FyCm with fail raccounfl effect.
nn3 of tar Raine.<s nnA Profeusians Cnde,anA ley license 920 1•,'•GI, FT. ADDTN -
<6,m is in full lass anJ,liver.
z < Date c Class Lic M
Dote Cnnle¢Im - - •w• , C • . - '
5uy - ARshall Ibe te,cl."th RATION - °`IN,t�"�LGD`
C O g 1 0maem:nul my plans shall he toed ns public teutmn'. eG - ...
ip C Licensed Pmfessionol w ,
- OWNCR IDECLARATION
I hereby frn his 1 ourn col Than thou.C coramm'Licare,Law for he _ MAY O 6.2 002
t
C' a till y-'
(Sc,linn 7031 S.Rusairs,z I to...fic,sina,C d ,Aty any racttoy 'h i, ,
❑ which 9 i crinint to construct. Ira P docanali,lo,orrtp' any wuurt -
pricar to its issuance also requires the applicant for such permtto rile a signed statement 7
a that he is licensed pursuant to the previsions or the contractors Gceaw Law(Chapter 9 , •Sq: Ft. FI tl
(ce g withS f 7080 1 6 s 3 of the Is dPrf.. :Camel ,
ladur,l ,in herefamr,and,h basis farmer alleged c pt aAy inlinfinin
bis f 7o3lsny rlrl u'r p t: li,ama qpl m, adv ll,tohy
ran,tmttemanrvennmuredaou,mttxro>� . ' APN Number -. Occupancy Type
❑1 nn t I m therselecom non ^ "37536007 r00
r rc 5 r employees Pensa
will oln this all nor flu,a t t f d l ft o f sale(`, l ]6f4, 4•
ow d f Carl, The a t , 1 ue 1 t pl ly m in . RCt � �{,`+peetls, - ••
owner fproperty uwh hurt, n 1 'm , mewl, doors: 1 sited or 101. —' FOUND Vt�ON
or ahnmgh his own entpl,Ytet pmvidin thu0 mph im rent is to are not mot, c r of '
infrared 7.02 — PIERS
completion,the,we ul orlmer will have the burden of proving tato he did not buil)or '
in,pmvc rm Pntpe,e nlsme.)' � 103 — UFER '
t, •
.01,re,iniont,an hepmpeny,a e.,lunivelyemdmningwhltfieansedemtlmnnrsm 104 — REBAR -
constmctdhe project(Scc.7044,Business and Professions Cadc:)The Commnor's -
License Law doess not apply to an(ownerof prepeny who build,ur Implication,theater, 1,05 — ANCHOR BOLTS
and who rads for such Pmjeeta with a cummemr(s) licensed pursuant m The "'
cnnfrT 'aL enacLow. 1.06 ;— SEWER & WATER ..
tae nnaaSeC_'- B�11Cfar its terser
202 — UNDERFLOOR PLUMBING
°` ° G I 'NSATffE" ION Dec nRAnDN 203 - UNDERFLOOR MECHANICAL
Ihereby
union mookper�aTyorrejmyrum orthe nia%ngdeclnmrmr, 204 .z UNDERFLOOR FRAME
❑ Ih 'aawdl
nCertificate of Consent in self-Insum for Workers 205 UNDERFLOOR INSULATION
Construction, as pmrmedfor by Section 3701 of.the Liber Code, for the ` 301 — ROUGH PLUMBING .
,serf nuance of the x rk for which thisperm t is -ual
Cl I false II ne n n w k e msen,afl I : c ny ti, fon 302 — TUB &, OR SHOWER .
3700 nn Lan cm r 'hPch net rat k f fah this pr i t is 303 —' ROUGH MECHANICAL
issued.My we,kerac npea,ata,i Insurane carrier
and rorty nnmner arc. 304 — ROUGH ELECTRICAL
Camey: facility No.: _
CP.R'I'INCATIONI IP EXEMPTION FROM WOR KERS' '305' —u FRAME "
' - COMI•17NSATION INSURANCE
arms sectron neea not be n�nnpletea inne prrmiT is farunclundredoluimre . 306' •—. HOLDOWNS
(slfterless.)' • 307 — INSULATION
I ten' m roe pnrrm�,ITnta ohne wore fa wlaah mi.permit is isa,.pl,�` 3@8 — SHEETROCK
ring rant a uT ,emon n-T�inner so e,to nea,me son t m me workers 309 — EXTERIOR LATH
Com nLa at Ca jfe /j
¢uhf �
NoncE rLlcnbn 'kingth ttneutthe Lads"Clare, 310 — INTERIOR' LATH
become whlecuo Th eta k C oras tsar ....Wines nhel.ber Ccount. end
C z0 rnrntwTnTcmdl,lywdt aanpr n,t s r.flus pe.nt,hauxae,Ttearcvnkenl 311 — ' SC-RATCH. 'CDAT -
z ` 313 — ROOF NAIL
CON3em is u(ON NO AGENCY
> I hereby aRnn this then is,issued ce. lending agency for the performance
of the work for which this pcm,iT is issued(Scc.3097,Civ.C.) � 501 FINAL 'ELECTRICAL -ENERGY-
W o 'Lender's Name
z Leader's Address 502 — FINRL PLLIMBINC,,'ENERGY
u O1 certify thatIbaverewntisapplication andstatethat the an,veinromtadonis 503 FINAL MECH NICAL ENERGY
le. E✓ correct.I agree to comply with all city and county ordinances and state laws staring 504- — JFIALELE
BU I I . I NG 'ENERGY ,
O V to funding lerstmainn.and retch,awhorire reprevenmtivea of t his city m emcrnram
y W he ohovt.Tnennonen rropcnr Ina oslccfinn Imposes" — RICAL(W) g f,su d nlY:mdk fl' Tess theCty,I Cupert nn g'In,im nabE
t f: d xpen.aes n n y in any way occme again t alp 06 — ST '
.V Z Citynhe gm i g tithe:pe t '
APPST.'y�d��pVDWILLCQMPLYWITHALIYNONN'. INT t lssuedb S BIND pate - �����
SOUIOh // Oink— �—��� — Y' —
,g VCGtLt r_ Re-roofs —
HALARDOUSMATrR1A1SDISCLOSU r 509INAL GRADE .will th applest o f rare building Ra,.tare or hanJlc hmatewl Type of Roof
asdPo dby theCapin M icipolC hupler'>12u Id Health a ad safety 51, — FINAL PLANNING
Costa.Secret 25512(n)
°Y N" All roofs shall 115 Apemer I�fKo a ��I�l sin installed.
Will the applicant or future bildingrcc p equpm fo a ict"hish If a roof Is installed without first obtaining an Inspection, I agree to remove
emit hawrd u.air nmammant a defined •ray A t Quality Management
District? all new materials for inspection.,Applicant understands and will comply with.
,Yes' all non-point source regulations. -
1 have read the haza doom"h uterials requirements under Chapter 6.95,f the
Cerium.Health d Safety Cude.S,eduar s 25505,25533 and 25534.1 understand this
if the hail 'of does nm, nn
have erall fait it is mam
y realsibility m notify the •?
ocdt th req, , fs wldch moot be act prinir m i...ante,of a Cetifcew of r ,
`r fig y/7 Signature of Applicant Date'
owills oaf mt,makti�'`�"'-� .�`P . _ �z � - All roof coverings to be Class"I3" or better,.
CITBYt OF GUPERTINO CONTRACTOR INFORMATION:
PERMIT
`nff Vf.ADb"G OHANSEN PERMIT NO. 00050149
O"VEIMI'DGE, DONALD/MAVIS APVI.JA)llnPP .6FO0
PHONE: SANITARY NO. CONTROL NO.
H re0 C'ARCHITECT/ENGINGRR: BUILDING PERMIT INFO
m w C BLDG ELECT PLUMB MECH
IJ L] I...-I
¢a
y"o
LICENSED CONTRACTOR'S DECLARATION
S Section
b ).f thin l n 3.f,ha H under ion,CW,..rd(commencing escription
iz=o roe vrn,haiumu P s 920 SQ. FT. AD)
with full ionIDWl affect,Division the Homestead Profnsioro Code.una my license
l:t
is in full forte and effect. -
:z m 6 License Class Lie,n -
f 0 LL N Data Convacmr
ARCHITECTS DECLARATION
O 1 understand my plans shall be used as public records
a-
1 i O O Liansetl Professional
o
OWNER-BUILDER DE CLARATION
uvi-roe I hereby affirm that 11. exempt from me Costas a License Law for the v / $88881
following�ea.(Section]onstr Business and Profusions h.or Any city announce E?O which requires a issuance.also
re construct,alcor,improve,demolish m repair any nature
.3 that hor oiucarawaalsor<quirtnhovisioam for sucCo mtmes Licale e,Law(Chapmned nt
thmbeislfcenad pur5vammthc provisions Division theCommitteesBusiness
Wad P.a,,i.ns ter9 _ t A Valuation
(commencing with Sectiont]OOO)of Divisionlaf the Business and Professions Code)
or that be is exempt therefrom and the basis for the alleged exemption.Any violation
of Section m "1031.5 by any applicant for a permit subjects the applicant to a civil penalty
.of a., arean five hundred dollars 5500). 10 N " Occupancy Type
❑L as owner of the Property,or my employees with wagesas their sole compensation, 102 - PIERS
willdothe wvi and the nmcture is not intended or offered for sale(see:70u4, - Required Inspections
Business and Professions Code:The Contractor's License Law does not apply to an
owner of property Who builds or improves thereon.and who does such work himself 10 4 - RE BAR
or through his own employees.provided that such impromments we not intended or
offered for.sale.If.haw<w, heWilding6,iiii,nowmenfis dd.Man..ayas,or -" --105- - 'ANCHOR -BOLTS
mompletion,But owner-Wilder willhave theburden ofpmeingthat hedid not build or 106 - SEWER & WATER
prove tar purpose of sale.).
—" 202 — .UNDERFLOOR PLUMBING
❑I her f the property,7 n exclusively contracting licensed The Crram blo m }
eon t net m project 19 m44 B t a and Profession,lade l The Cor tm mod, 203 — UNDERFLOOR MECHANICAL
neo
License Law does not apply m an owner of pmpeny who builds ord parson thio the
-. : '_
and who contracts for such projects with a contmcmr(s)licensed pursmm to the .., 204 .---_UNDERFLOOR_ FRAME _ _ - „_. ,,,_ ",__
eontraemsLicenseLawi . 205 — UNDERFLOOR •-INSULATION
❑lam exempt under Sec. ,B&PCfonhis reason 301 — ROUGH PLUMBING
Data
Oxver" WORKER'S COMPENSATION DECLARATION 302 — TUB & OR SHOWER
Ihereby affirm a.theeltfd
rPnayoprjury;nneofthfollowing declarations: 303 — ROUGH MECHANICAL
owngecaratons:
g�L''•o l have and will maintain a camr<atc or emraeht to self-insure for workers 3 04 — ROUGH ELECTRICAL
i Compensation, .1 ....ided lm by section 37W of he Lubar Code, for he
p'boaana bone work lot which this pgmit is issued. 305 - FRAME
305 5 - HOLDOWNS
O 1 have and will maintain Workcr's Compensation Insurance,as requirW by Section
37W of the Labor Code.for the performance of the work for which this permit is 3 07 - INSULATION
issued.MyWorker acnmpehaahopInsurance number and Policy number art: .308 ._ ..SHEETROCK
Co.a,: .a.., t ,. ' .:Policy No.: .._
t CERTIFICATION OFEXEMPTION FROM.WORKERS'-' 3 09 '-' E'XTE'RIOR_
-LATH `
coMPErISTION frvs�anNCE' : _....__._�... ...3,10.........INTERIOR ,LATH..... .._-:
' (This sect on teed not be completed if the is for one hundred dollars 3111 —! SCRATCH COAT
on)()uneaa? 313 r ROOF" NAIL_ .
—_. . . ..
1 comfy mat in tG pert mtaoce of the work for wnah this permit is issued,) 315 - EXT SHEARS
�ItCom not employ any person m any ma r ro oa to become aageFt to me workers icant 402 - TEMPORARY POWER
Compensation Lars of California:Data
rte '
NOTICE TO APPLICANL If,afar making this Certificate of Exemption.youshould 501 - FINAL ELECTRICAL -ENERGY
O pbecome subject to the Workers Compensation provisions of the Labor Code;you must
forthwith comply with such provisions or this permit shall be deemed revoked. 502 — FINAL PLUMBING ENERGY
..
. . 503 = FINAL MECHANICAL ENERGY:'.' +. : .
.-
E.4 '`t` .'s. CONSTRUCTION LENDING AGENCY '
a'� heThereby waffimhich thin thereisa construction lending for the performance 504 — FINAL BUILDING ENERGY '
W.;O Leri a work for which this permit is issued Isle.7119),Civ.CJ
y der'aName 505 — FINAL- ELECTRICAL —'
UZ Uneer'anaI Address , . 1 506 — GAS TEST"
I candy mat I have read this application and state that the above information is
lam;: correct,I agree to comply with all city and county ordinances and state laws relining 507 — FINAL PLUMBING
O.r_y to building ammonction.and hereby minimizerepresentatives ofthis city to enter upon 508 — FINAL MECHANICAL
(f] the above mentioned property for inspection purposes.
-00 (We)same 16 saw,indea lryandkee,harmmsatheCityofClaq�i.inforst 509 - FINAL GRADE
.to liabilities,iudgman¢,cons and expenses which may in any way acme against said
U:► city in consequence of the granting of this pendil. 51 N ING
]CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTIssued bI
S Date RK
Siturvicarammitor
Will the pplicam ,future bd ld ng D"`' Re-roofs
anfAppl HAZARDOUS MATERIALS DISCLOSURE FINAL REROOF
p or handl himdoussumbrial 60.
Type of Roo
as 3.and me He hh antlS Iety _
Cod b,the
Section M c I CoChapter
Ely s p ❑No de cis pt 91 All roofs shall,be,mspected prioryto any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtainingan inspection,'I agree'to remove
nit haurdous air contaminants as defined by the Bay'Area An Quality Management
istnml . ', . _ all new materials for inspection. Applicant"understands and will comply with
D
, ues ONO all noti-point source regulations.
1 have read the'hazmdnus materials requirements under Chapter 6.95 of the
Califomia Health&Safety Code,Sections 25505,35533 and 25534.1 understand that
Ithebuilding does notcurrently have arenas that it's my responsibility to notify the
i ect p m of the y c t h'ch must he t p e,to isau f a C ni0eme of
Occ pony
Signature of Applicant Date
r' own roramlmnzed,g t
One All roof coverings to be Class `B" or better
. . .. OFFICE .. . . .. . . . . _