02040162 OF
CITY
DIVIISSIONNO
IPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
6440 MYRTLEWOOD DR BOW JANICE K AND RONALD 02040162
OWNER'S NAME: APPLICATION SUB DATE
BOW JANICE K AND RONALD A 04/30/2002
PHONE: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
6 1e L= I
FF LICENSED CONTRACTOR'S DECLARATION
O to 1 hereby affirm Thal 1 am licensed under provisions of Chapter 9(commencing Job Description
with Seeinn]WO7 of Division3 of the Business end Professions Code.andmylicense REPLACE 220 V ELECT OUTLET
mm is in full force and effect.
iC License Class Lic.I
Data Contract.,
1 O t�, ARCHITECT'S DECLARATION
1 understand my plans shall W used as public records
1 E5 p O Licensed Professional
OWNER-BUILDER DECLARATION
-�' I hcmby affirm Nut I on exempt from the Co ed,tim's License Luw for the
I- a following reason.(Section 7031.5,Business and Pmfessions Code:Any city or county $100
E F O which requires a Milan m construct,alter,improve,demolish or repair any structure
3� Poonoiu issuance.also requires rhe epplicmt(....ch parent mfile asignalsummcm
Haat haik heeused purauanud the provisions of the Contractors License Law(Chapmr 9 f r' Valuation
(commencing with Section7")of Division 3t.fine Bpsineu and Professions Cadet C0V!f ,361&LUiV'L[ ,-U,pt,1,'s �t'�(i� ;
or Nat he Is exempt theiefrom and the basis for the alleged etcmytiori.Any violation
of Section 703M by any applicant for a permit subject the applicant to a civil Malty
of not dame than fivahundred do[]. S500). 30eN ffH ELECTRICAL Occupancy Type
01,as owner of the prapeny,or my employees with wages as their sole compensation,
will do the work,end the structure is net intended to opened for sale(Sec.704,1, strm �s�tT,ta�a,
Business and Pmfessions Code:The Contractor.License Lew does not apply to an 505 - FINAL E R W1j R'1'Mt;tlons I`
owner of property Who builds or improves thereon,and who does such work himself
or through his own employees.provided that such improvements art not intended or
offeed for sale.IL however,the building or improvement is sold within one yen,or
completion,the owner-builder will have the burden or proving that he did not build or
improve for purpose or sale.).
-- 1 L asown_.. .. . .. . . . .__ ..g h licensed .., _ . .. .. . 7._... _ . ... — —
❑1st;owner f the property ore ex sines a contracting with e Contractor's m - B' '.. t
construct the p eject(Sec ]044 Business and Profess ons Code)The improves
t e thereon, ,
License La dines not apply men owner or property who) Ids se Improves thereon - -"
and-who,.contractsforsuch projects with a comractor(a)bcensedpursuant to the .. _ __ _ _. .. __.. sow.......
1
Cythrn License Law. _nder Se & res
-'
7u pt uP C for this in +
Own, - e � 0v .
-WORKER' PEN�TION DECLARATION
y I hereby aRrm under penalty of Perjury one of the following declarations:
0 1 have and will maintain a Certificate of Consent to self-insure for Worker's1
Compensation, as provided for by Section 3700 of the Labor Code, for the -
_ _ performance of the work for which this permit is award.
01 hive and will maintain Weiler',Compensation Insurance,w required by Section
= 3700 o0 the Libor Code,for the performance of the work for which this permit is
f issued.My Worker'a Compensation Insurance carrier and Policy numberare:
Gainer 1,.l --' Policy bre
tl CERTIFICATION OF EXEMPTION FROM WORKERS{
, CO1.1. i IONJNSURANCE"0,.r, . .--.: ,c, ., _..__.__._.._-.___._...----. .._---.----_____-,.__..___.__...__-_._._____.__...___..._.............
.. ._-....
rC" (This,aection need not he'campleted if the permit is for one hundred dollars
(klBl))Of refit.)
.., 'Ir rtlfy that in the,p �mg
rkrr h thispedon Issued,11
LJt
hell t mpI y p any q}ycaVfc�uhr r t th Workers
7f// ifon o��h( " '� ,s -OA LICANT IfCEnifrcem o(Exemp"an souphould t
O Qbecom,subject to the Worker's Compensation provisions of the tabor Code,you must
forthwith comply with such provisions or this permit shall he deemed revoked. •I
CONSTRUCTION LENDING AGENCY '
1 hereby-affirm that dam is a construction lending agency for the Performance
of the work for which this permit is issued(Sec,
3097,Civ.C.)
Lenders Address . . ..__ .._ .
V � L cenify that 1 have lead this application and sum that the above informatian is -
fT+_F corizi:I agree to comply with all city and county ordinances and state laws relating /t
0_V re above-mefid ntioned
propeahertbyauthoomreposemmives of Niwity to rnmr upon / /�� � t
--W the nbo(We)Qionrd propend for inspection purposes. V/
6i (We)agree to save:and expo and keep harmlcw the way
of Cupertino e I aid
Z liabilities,judgments,costs end expenses of this
which may in my way accrue against said
V � City consequence of the greening o(thiepermit. '
APHn UNDERSTANDS N VTLLCOMPLYWouALLNON. MT Issue 0Z/
SOU P F dILAT N „/ y Dale
�i ria"re bf Applic HAZARDOUS
m U - dm'-'- Re-roofs
HAZARDOUS MATERIALS DISCLOSURE ,
Will the applicant or future mildirig Occup t store or handle huaidous mammal Type of Roof.. -
as defined by the Cupertino Municipal Cod Chapter 9.12,and th Health and Safety
- " re -
Cecil
.0Yes 255R(e) /.:,/N 1 L, 1'.I �' I st d iPy 'j": �. T•,r p.
LYC } _-All roofs-sball,be mspectei poor to anJy,roofing material being installed.__
Will rheappliamor future building occupant useequipmentordeviceswhich If a roof is installed without first obtaining an inspection;I agreet6remove
emu huaid us air conmminants efinWb)thBay ArmArQuality Management
Disdi t all new materials for inspection. Applicant understands and will comply with ,y_
❑Yea - _ ..
all non-point source regulations.
1 have read the hazardous materlals rtquimme us under Chapter 6.95 of the '
California Health&Safety Code,Sections 25505.25533 and 25534.I u icadmnd that '
iftla, uImding does not auremly have a tenant,that it is
my responsibility,.really Ne
occupant a(the ircromis which must be ,at pd....issuance of h C ificem of -
°Pa sy' " Signature of Applicant Date
All roof coverings to be Class"B" or better
wner or ambo agem coverg
�.: , .
OFFICE..