03010144 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRAORaINFRORMATION:
BUILDING ADDRESS: PERMIT NO.
20171 JOHN DR 03010144
NER'S NAME: APPLICATION SUB DATE
PURUSHO WALTER K TRUSTEE 01/24/2003
IONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
0 0 o
WOO LICENSED CONTRACTOR'$DECLARATION
e U F 1 hcreM1Y gqqqlfirm that firm licensed under provisions of Chapter Y(commencing lob Descriptiq�B /� as ,y
tai with SeninaT(Xiil of DivisionJof the BusinessanJeddlncrcode.andmYliccnse is 9'" yT 4L rE
inlofiromr MASTER BATHRM REMODEL
Zon? Lwcnu Class — I 'I"
°_— cmaacto
ARCHITECT'S DEC TION FEB 1 12003
t<"y
K re K I understand my plans shall be trod as public records
apwa
LL0G Licensed Professional BUILDING
or I OWNER-BUILDI?R DIiCLARATION
uiax I hereby affirm that 1 am exempt from the Contractor's License Law for the
or o O following rem,(Sermon]11)1.5,Business and Professions Code:Any city or county
n'w m which requires a pemat m construct,alter,improve,demolish,(it repair any structure
prior to Its issuance,also bNoms the applicant for such permit to file a signed statement
ischer he is licensed pursuant to the provisions of the Contractor a Liecom Law(Chapter 9 Sy, Ft. Floor Area $7W017ation
ne
t_ (commencing with Section7(XXb of Division 3 milk Businea and Professions Cock)or
y 3$ Nat he is exempt therefrom and me basis for me alleged exemption.Any violation of
Section]031.5 by any applicant for a permit subjects the applicant o a civil penalty of
W,more man five hundred dollars($500). be Occupancy Type
❑I,as owner of the propury,or my employees with wages az their ole c^mpeneadon,
will do the work,and me structure is not intended or offered for sale(Sec.7044,Business
and Professions Cody,The Contractor's License Law does not apply to an owner of 102 — PIERS CCIUIred Inspections
pmpeny who builds or improves thereon,and who does much work himulfor through his
own employees,provided that such improvements arc not intended or offered for sale.If. 1.03 — UFER
however,Nc building or impravem=nt is sold within one year of completion.me owner-
. builder will have the burden of proving but he did not build or improve for purpose of 104 - REBAR
su'le) 105 - ANCHOR BOLTS
❑l.as owner of the progeny,am exclusively contracting with licensed contractors to 106 — SEWER & WATER
conswet the pmjeet(Sec.7134,Business and Professions CmR:)The Contractor's Li-
mmalawdoesnotapplytoanownerofproperty who Wilds or improves themon,and 202 — UNDERFLOOR PLUMBING
who contacts for such projects with a moombefa)licensed pursuant to the Contractor's
i rose Law. 203 — UNDERFLOOR MECHANICAL
I am exemp oder Scc. B&P C fnnhis reason 204 — UNDERFLOOR FRAME
I A!, �' Good 0 205 — UNDERFLOOR INSULATION
WORKER'S COMPENSATION DEC�-LL��RAJJION 301 — ROUGH PLUMBING
Ihereny amtm ander penalty of. otc ottlt.rdlf'wmg eemaamnna: 302 - TUB & OR SHOWER
❑I have and will maintain a Certificate of Consentm self-mom,for wmon,sCompcn-
aamun,as provided for by Section 3700 of the labor code,for me performance of In, 303 - ROUGH MECHANICAL
wook for which Ill,pcond istssoed. 304 — ROUGH ELECTRICAL
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3 0 5 — FRAME
3'11x1 of me labor Code,for me performance of the work for which this permit is issue).
My worker:Compensation Insurance eanimand Pofirynumber am: 306 - HOLDOWNS
Carrie` Policy No,: 307 - INSULATION
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 308 — SHEETROCK
Trois accdon nccd not he cordic"dif the 1.111,for one hundred dollars 309 — EXTERIOR LATH
or less.) 310 — INTERIOR LATH
ecertify thin in the in
sande of the work for which this permit is issued,1 shall not 311 - SCRATCH COAT
Laws
any pcmm in any mano=r m as m Meurer subject m the Workers'Compensation
Lawsca California.Da" 313 — ROOF NAIL
Applicant
NOTICE TO APPLICANT:If.after making this Ccnifcate of Exemption.you should 501 — FINAL ELECTRICAL ENERGY
M1cntmc suhjce,m the Worker's ComPcnxmi=n pmviuions of the Labor Curie,you must
O Z forthwith comply with such provisions or this Permit shall the deemed revoked. 502 — FINAL PLUMBING ENERGY
z 0 CONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL ENERGY
F I hereby affirm shad them is a consmiction lending agency lot the ixerformance of 504 — FINAL BUILDING ENERGY
the a > Underrk IxNameichlhis rmilisissued(Scc.IIW],Civ.C.) 505 - FINAL ELECTRICAL
41 0 Lender's Name
� Z nderanaJma'` 506 — GAS TEST
UO Icrnee that1haveread his
ty dicand cionsaddinamat for abovewscluningis 507 — FINAL PLUMBING
/
U mrrcm.l agreto e I have
with all city and courmy adsim 'barand sure information
to
OU building construction,and hereby aumnrim representatives of this city to enter upon the 5 FINAL MECHANICAL
arove.m annowd property for inspection purposes, *— F E
(We)agree to save,indemnify and keep harmless the City of Cupertino againfn liabilities.judgmene,cosh and expenses which may in any way amore against said City 5 GsU ,Z in consequence of the granting of this perm it. IAPPLICANT U DERSTANDS AND WB.L COMPLY WI TI ALL NON POINT Issued bys WORKS Date e
SOURCElR I,ATIONS. /
�Td Applicint/Commoor Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE^ Type of Roof
Will theappliaamorfuturebuil 'ng rxx" or store 2, handle harallous material
ns JcfineJ by the Cupeninn Muni, Cute,CIt re,9.12,and the Hcaldt and Safety
ae.sr yt., s53xar! All roofs shall be inspected prior to any roofing material being installed.
❑Ycx No
Will me applicant or film In
mca ant tree preen If a roof is installed without first obtaining an inspection, I agree to remove
P' 4ui t m devices which �' p
mit humNnus air conWminanty91 dined by the Buy Arca Air Quality Management all new materials for inspection.
❑Yc<
1 have mad the hamNnus materials requirements under Chapter 6,95 of the Califor-
nia Ilcalm&Safmy GNc,Sections 25515.25533 and 2553.1 i nricmand mat if the huiWing
docs no,,u m 0 have a enam,fth�e n e,my responsibilhy m notify t e¢c ant of Ne
req�atrcmc^t, " hrural nmtrismanceofacemframnr4 r' Signa[ureofApplicant Date
/ zv — )
6�mor aothmimd agrm D„e All roof coverings to be Class "B”or better