02010018 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
20184 NORTHGLEN SQ 02010018
OWNER'S NAME: APPLICATION SUB DATE
RODGER WERT 01/03/2002
PHONE: SANITARY NO. CONTROL NO.
kL
Cie.O ARCHITEC(ENGINEER: BUILDING PERMIT INFO" ❑❑ BLDG ELECT PLUMB MECH
caLIC
lFoan _ _
Z or"it� I hereby affirm Aa l amSED ttud underr provisions of Chapter 9(commencing OR S DECLARATION Job Description
�ZF-o wi lion 7000)of Division 3 of the Business and Pmfessi°ns Code,and my license FIRE REPAIR
full tura an Ren ,
_.W< Lsave Class
see.« �607e/
O w Da Conuaaor
ARCHITECT'S DECLARATION ����I� �«i
g 1 understand my plans shall be used as public records
aw T�
<0 Lres sed Professional 1
g°S OWNER-BUILDER DECLARATION MAY 2 6 2002
X 1. I hereby am.that I am eacmpt from the Contmnor's License law for tM,
1—Z a follox'ing reason.(Section 7031.5.Business and Professions Cade:Any city or county $5000
Exp which reyuirea a permit¢,rnnsrma,vlter,improve,demolish,nr repair any structure
i3m .poor to i¢issuuwa also reyuiru the applicamfor such permiuotilon signed sa¢ment
Nm he is Ec'ntcdpursuonuo Nepmvisions of the Comram2s Liccnx law lCheptcr9 ea-, Valuation
(<oormismng with Secdon]00%of pivizionSof the Business and Profusions Code) f, .i'• s3,15 j a.'V.V.Ja:.t ar ate. lr
-.'
or that he is exempt thercGom and m<basis for the alleged escmpuon.Any violation
"of Section 7fi,I,by any appl'mand l°rat permit mbjttaa the npPlicannoacivil pcwhy 1,a OCCU
of nor more man five hundred dull...S500),0). 101 APN�ftATION Occupancy Type
❑1,as owner of the property,or my employees with wages as their sole compensation.
will do the work.'and the structure is not intended or offered for sale(Sec.-7044.
Business and Profession,code:The Commcmr'I License Law does not apply to an 103 — UFER Required Inspections
owner of property Who builds or improves mercon,and who docs such work himself.
or through his own employee,,provided that such improvement,are not intended or _. ._ .__ 104 - REBAR
offc4s•A for sale If howdsr,the building oi]mpmm
veent is sold-within one year of ---�—
completion.the owner-iswill have the burden of proving that he did not Wild or 105 — ANCHOR BOLTS
ilder
improve a,r pumn.e or,ae.). 106 - SEWER & WATER
❑Lat,owner of me pcny,mpam exclusively contracting with licensed contractors to
constructthe project(Sec.TW.Business and Professions Code:)The Contractor': 202 — UNDERFLOOR PLUMBING
License Lawdoes not apply to an owner of property who builds or improve.,thereon. 203 - UNDERFLOOR MECHANICAL
[.'
,and who rmmamv.mr.meh.projens with a cnmmnnrta),Iaen,sd.pmsuantt..the -- ------2 0$ _ UNDERFLOOR -FRAME - - "- —
.----- ---
0 1 ....
Contractors License Low.
ata exempt under Sec.,'- ',B&'PCfor this reaun 205 — UNDERFLOOR"'INSULATION
o'wP=r. • " '" Data 301 — ROUGH PLUMBING
"WORKER'S COMPENSATION DECLARATION
I herebyaBion under h r ° one of Ne followingdeclaration., 302 = TUB & OR SHOWER
°"' y° p ' " 303 ROUGH MECHANICAL
❑ I had¢and v iB morion a Cemificae or Convent to.eleinx°re for Worker's 3 04 ROUGH ELECTRICAL
i_ti f CnmpensmIran. as provlded for by Section 37W of the Labor Code, for the
pc famnooc of me work mr which this .it i,issaed. 305 — FRAME
01 have and will maintain Worker:,Comwnsaaon insurance is"uimd by 5mtfoa 306 - HOLDOWNS
37M of the W Wr Code,for the performance of the work for which his permit is
i d.M wo.ke, Crrm ationhis once carrier and Policy number am. ,. 307 — INSULATION
c u �Jl, o as / , , e 308 SHEETROCK
ER 1FICATION Of KEM1IPTION FROM WORKERS", 369 1 EXTERIOR LATH
COMPE ATIONI\SURANCE -_ _
(Th s section rc d not b c repleted if the fern t is for one hundred dollars 310 t,- INTERIOR LATH t
a10o)orleaa) 311 — SCRATCH COAT
—
313 `= ROOF `NAIL —
1 cert ry`tAai n the performanceof the work for wh h th perm t is issued I
sn B' l piny any ps` i ' ytr as rn beeo ne.nmeatt me workers 501 - FINAL ELECTRICAL ENERGY
Co.
finer s°
Cmaro,ouon Laws til Calnornm.Date "
A",ca r.' - 502 - FINAL- PLUMBING" ENERGY- -
arm's
NOTICE TO APPLICANT:B,aBcr making this Ceniaca¢°f Exemption.you should
t.thepnvationpmvmnnspnnELWrcoe,y°°moa 503 - FINAL MECHANICAL ENERGY
Z Oz 'come Osnhwo,comply with xa',pmv
i.....or mi pe mit+nau be deemed revoked. - . 504 FINAL "BUILDING ENERGY _ ._._. _._ .....
.Fr . i : CONSTRUCTION LENDING AGENCY 505 — FINAL ELECTRICAL , \
Lender's work
far . Senq fordo,performance
q t<the der,Name.-hick this peimit is:°w�i�l`s«�io97�ci+;.c.l „t_. .- - -- 5.06 . GAS.. TEST. ------ -- --- -- -_. - _
gat
z 507 - FINAL PLUMBING.
.0 O Icenifythalhave mad this applicmionand shrethat the above information is 508 — FINAL MECHANICAL
W,F. cortect.I vgrtt m comply wait all city and aunty ordnance,and some laws relating 509 — FINAL GRADE
O U rebut Wing nmanclion,and hereby'authmis rrpreormativice of this city m enter upon
- W . heabove.myna°nedpm,cnyf... r,,rImmparfnscs.... 510 — FINAL PLANNING
rA. (We)agree pi Jmnify and¢ ph Icss,h City fCupenmo against
V3 I b I't , Jgmem e.u d y. which ay in a as y sccNe ngaina said 514 — FINAL U 0
U z Cly 9vence ffla, tug oft permit. r _
sn Ir' TONT ERSItN tS'r Nps ILL COMPI, UH ALL NON-POINT ISSUedb Date ( � O�
ely
r fAp Ic t tt bu ldi occupant -09^o y.
HAZARDOUS MATERIALS DISC
Data Re-roofs
1 g n DISCLOSURE material .,._Type of Roof. -_,-.---•.. ..
a defined by he CupertinopBE
Code Chapter 9e° h nJle head -"-
UUF Cf'1L4710N5
pP g P •-
12.and the Health and gatctY
Coda Section 25532607 .
ovs :'" ' ON. .._ a"All roofs_shall-be-inspected prior io any.roofing.material being installed..-__
will toe i"Pli,am orf t mild, tp ta=e ,i,onsm devices which If a roof is installed without first obtaining an inspection, I agree t'o remove
10son,b N s it nix ai del Jhy th ByAre A -Q 'I'tyMngcthent
D t f all new materials for inspection. Applicant understands and will comply with
0` 0 s all non-point source regulations,.
-� (,bliuve.rcarl the hazardous mamnals reyuircnienu tinder Chancr`655"of the
California Health h safety Code ecrons 25505,25533 and 25534,1 undrsmnd that . .. .. .. . .... .. - ..
if the Wilding does not come
ydy ha a tenant,that it is or,responsibility m notify the -
occo t of the m, ems is xhi nun be met p'or to mi....e of a Cenifcam of
e 0/-O3i-G a Signature of Applicant Date
tier ontnn�.m agent _Dae All roof coverings to be Class `•B" or better
OFFICE - -