02100150 C1TV OF CUPERTINO 4-0%* 'Qf ,in�;,�?}P'*+s&r3"ii,
BUILDING DIVISION PERMITCONTRACTee, OR,INFORMATION:
,,, .,
BUI�gIQ0DWs:HILL LA CLEAR OAK DESIGNS PERAuTN02100150
mCON49JOHN R AND LESLYE C 1723 B ROGERS AVE APPLICATTOSpTDIT�2002
PHONE: (408) 436-5448 SANITARY NO. CONTROL NO.
ARCHITLCI'IENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
�Op LICENSED CONTRACTOR'S DECLARATION /�
�m F I hereby affirm that 1 am licensed under previsions of Chapter 9 <ommencin L®®
a with Section7IXkpofDi,mort 3of the Businexead Professors Cele.Orem,Beene is KITCHEN REMODEIl°bD �
mom in full licca and ca.
F N2l �SuokacC.IIr@� 0.3
C4f �5 FEB 2003
£ ARCHITE DECLARATION -"
�oWiL u IundcStandA nY p`n nal�M�.�psruh�i�cnNa
w LLOr Licensed Pt cssional RD BUILDING_11 OW NIim exempt ER m the Comas, ,Y
<5 1 hereby affirm that 1 1. exempts an the Cnnwcurt s :Any c Law lie she $20000
ii 6 0 0 which
re rinse a Permit
t ]1131.5.Business and Professions Code:Any city of roomy
$ which its requires a permit requires
e mneme,alter.improve,h Permdemolish,or repair any swnure
pooOat he i licensed
pursuant
n t it)he the
ovisio s o for sucContrarmiuo fileLicense,
Law(s Idcmcm
O thmhciscingwid pursuant to the previsionsn ofonBosoms,
osomr'slicense law.Chapter) 33g21?1:7Eh71 AfPa Valuation
$ (ttd W is xempteS mfro 7lknd of Divisionfr of theeged essuption.Any
Code)Or
s that he is exempt thcre(mm and the hue for the alleged exemption.AnY vinlaflinn of '
Section 7031.5 by any applicant for a permit subjects the applicant to a Civil penalty of PMN Occupancy Type
not mom than five hundred dollars($51M). 102 — PIERS
p y yp
❑I,u owner of On propery,Or My employees with wages a their sole compensation,
will do the work,and the structure is not intended or offered for auto(Sec.7144,Business
and Professions Code:no Conuactors License Law does not apply to an owner of 104 - REBAR Required Inspections
property who but Ids or improve thereon,and who does such work himself or through his
own employees,provided that such impowments arc not intended or offered for=te.If, 105 — ANCHOR BOLTS
however,the building or improvement is old within one year of completion,flee owner. 1O6 — SEWER & WATER
builder will have the W rden of proving that he did not Wild or improve for purpose of
=le) 202 - UNDERFLOOR PLUMBING
El I,as owner of the properly,am exclusively contracting with licensed contractors to 2 03 - UNDERFLOOR MECHANICAL
construct the project(Sec.7144,Business and Professions Code:)The,Contractors Li.
cense law does not apply to an owner of property who Wilds or improves Neeson,and 204 - UNDERFLOOR FRAME
who contracu for such projects wish a contractor(s)licensed pursuant o the Conuamor's
License Law. 205 — UNDERFLOOR INSULATION
❑l am exempt under sec. ,B&P C for this reason 301 - ROUGH PLUMBING
4knor Dam 302 - TUB & OR SHOWER
WORKER'S COMPENSATION DECLARATION 303 - ROUGH MECHANICAL
I hereby air,.enderp mOy of pedo,mad of did triturating dalandioas: 304 — ROUGH ELECTRICAL
thaw and will maintain a CeniOcate u(Commmu,self-imam for Worked Compen- 3O5 — FRAME
I,
satin,as provided for by Section 37W of the Labor Code,fnr the perfoonf nce of the
work row whichthisp. isissued. 306 - HOLDOWNS
❑1 have and will maintain Worker's Compensation Insurance,u required by Section 307 - INSULATION
374 of the Labor Cade,for dm p rt mr adc.of On work for which this permit is issued.
My Workers Compensation Insurance carrier and whey um Gra: 308 — SHEETROCK
501�o'3�P C Pnliey�u' 309 - EXTERIOR LATH
CERTIPI CO
COMPENSATION INSURANCE woRKens' 310 - INTERIOR LATH
(This sesit.need no,he completed if be permit is fnrone hundred dollars lkltg) 311 - SCRATCH COAT
of1C9S.) 313 - ROOF NAIL
I certify that in the performance of the work for which this permit is issued,[.,bull nut 5 01 - FINAL ELECTRICAL ENERGY
employ any person in any manner so u subject to become suhjeco(be Wormov'Compensation
Laws ofCalifornia.Dale 502 - FINAL PLUMBING ENERGY
ApplicaNOTICE
oushoold 503 - FINAL MECHANICAL ENERGY
NOTICE TO APPLICANT:If.afterCont making Nis Cisions f of Exemption,y
Wcomcsubject ly the Worker's Coons or tis Permit
tshal of themed rCudc,you must 504 - FINAL BUILDING ENERGY
Q7. (mshwi@comply with such pmvi.vinsonhis pormllehall be deemed revoke).
z CONS RUCTION LENDING AGENCY 505 - FINAL ELECTRICAL
(— Iherthy alarm star there is a conswetion lending agency lot the performanccof 506 - GAS TEST
the work((it which this permit is issued(Sec.3W7,CIO.C) 507 - FINAL PLUMBING
ftI Q Lender's Name
d Lendcr'aAddmss 508 - FINAL MECHANICAL
U O 1 certify that L have ithJ thirty and
our and stale that the shove information is 509 - FINAL GRADE
0U Curren.lagfceflocomply
n,addereall yotyaneMPM ordinnttaand atate enter upon
5 FINAL PLANNING
� building construction,and hereby authorlrc rcprcsenmflives of this city to enter alum the
shove-mentioned rtfor inspection purposes.
96 (We)agree msave,indcmm fy and keep harm less the City of Cupenims against 14 - FIN LIC W RK
rfA liebi lilies,judgments,costs and expenses which may in any way accrue against said City /� I
U Z in cimoqucnce Of the granting of this permi t.
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
RC REGULATIQNS._ p,��
a k P L—u-iY�a� 6zX__> 4 10121 Re-roofs
Signmure a pplicanVCnnuocmr Date
HAZARDOUS MATERIALS DISCLOSURE Type ofRoof
Will the applicant or future building Occupant store of handle h oddims material
s defined by the Cupertino Municipal Citric.Chapter 9.12,and the Health and Safety
We,Section 25532(a)?
El roofs shall be inspected prior to any roofing material being installed.
j7 No
❑Yes
} Will the applicant or future building occupant mccquipment ordevices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hannhots air contaminants as defined 1y the Bay Area Air Quality Management all new materials for inspection.
Distrin9
❑Yes Nu
I have mad the haomdous materials requirements under Ch ipmr 6,95 of the Cal did,
Dia Health&Safety Code,Sections 25N15.25533 and 25534.1 understand that if lee out lding
does not currently have a tenant.Nat it is my mormsihility ur notify flat Occupant of she
req remen¢wmm�ma beret, rmi=eancenraceninci thnpncy' SignatureofApplicant Date
caner or anmoriad agent
Dam All roof coverings to be Class "B" or better