03010194 CITY OF CUPEWI'INO 3 '-"- "` A ''t
BUILDING DIVISION PERMIT "CONTRACTOR W111
BUILDING ADDRESS: PERMIT NO.
10846 NORTHRIDGE SO 03010194
'S NAME: APPLICATION SUB DATE
IRENE Z BOWLBY 01/30/2003
PHONC: SANITARY NO. CONTROL NO.
ARCHI'I ECfIHNOINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
"OFtOp LIC17NSED CONTRACTOR'S DECLARATION
s U 1 hereby efGrm Ihat 1 am Ilccnsrd u Jer Pmvixinns of Chapter 9(commencing Job Description
with Sectima7xXB (Di inn3of the Bu�off umasions Code,and my license is CL86A 11 .4A 11 �®
s in full lbtss�pAJ effect W-6 / BATHRM REMODEL If 9V�Ipasll4a
GiH cILAR '1'10
I undcrmanJ my plans shall he uses public records FEB 2 5 2003
a Pal
Fer 0 LicenscdPrnlcxsienat BUILDING
OW NIwin eU1LDER DECLARATION
CoATION
z 0 0Y. I hereby reaso .ffornSect that 1 um exempt from the Cssion, o Licensee Law lin the
a 60 0 which
reason.(Semon]ton S,Business and vets demolish,
Code:Any city or County
w$ which requires a pcfmit In cnnstma,after,imprnsm,demolish,m repair any structure
FZepnono its issuance,also requires the applicant lot such pesfutno File sallied statement
that he is licensed pursuant o the pawisions.(the Contractor's License l.xw(Chspmf 9 Sq. Ft. Floor Area $20'0"tlon
s $ (commencing with Section 700d)of Division 3 of the Business and Professions Coke)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant fora Permit subjects the applicant to a civil penally of
net...than Ove handled doll..(MLC Occupancy Type
1,as ownef of the property,army employers wall wages as their sole compensation,
will do the work.and the sbuctum is Bol intended oroffered for sale(See.7044,Business
and Professions Code:The C.amm m'a License Law does not apply sen as owner of 102 - PIER S equMd Inspections
property,who builds or improves thereon,and who Acessuch work himself or through his
own employers,provided that such improvements am not intended oroRemd fersale.If. 103 — UFER
however,the building or improvement is said within one year of completion.the owner
builder will have the burden of proving that he did nal build or improve for purpou of 104 - REBAR
ssle'1. 105 - ANCHOR BOLTS
01,as owner of the property,am exclusively cmtwcting with licensed contractors to 106 - SEWER & WATER
construct the project(Sec.7044,Boxings.and Professions Code:)The Clinometer's Li-
censa law docs not apply to an owner of property who milds or re
improves theon,and, 202 — UNDERFLOOR PLUMBING
who contracts for such pmjrcts with a conmanons)licensed pursuant u)the Contract."s
'sore Law. 203 - UNDERFLOOR MECHANICAL
lam cse Sc. .B&P C for this reason 204 - UNDERFLOOR FRAME
a Dare '30' 205 - UNDERFLOOR INSULATION
OI R'SCOMP fsens IONDECLARA ON 301 - ROUGH PLUMBING
Ih1C 1,andwel mai"ain a Cenahyaf ofCoyeneofth m calor Wtlara'Co 302 - TUB & OR SHOWER
❑1hoar and will for
Section
37m of theani bsoCode,sumfurerformace of the
rasion,u provide)fur by Section 3]1X1 of the labor Code,lits the performance of the 303 - ROUGH MECHANICAL
walk for which this pemnitis owned. 304 - ROUGH ELECTRICAL
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3 0 5 - FRAME
3700 of the labor Cole,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy refuter are: 306 — HOLDOWNS
Critter: Policy N., 307 - INSULATION
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 308 - SHEETROCK
(Thtssection martinet to completed ifihe permit isforonc hundred Jollasan](X) 309 - EXTERIOR LATH
leas.) 310 - INTERIOR LATH
1 wt.y Nat in the pert"mance of the work for which this permit is issued,I shall nm 311 - SCRATCH COAT
employ any pC. n 'manner. �sw}IeLer�r s:�t�Workeri Compensation
Nawa ar .orad 313 - ROOF NAIL
App Ica, 0A L, f,after making this Cendmam of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
OOteen csubjecLt.theWe"Itr'.eCamprdsadomIrrovisionsaflhclahnrCode.youmust 502 - FINAL PLUMBING ENERGY
forthwitbcomply with such provisions or this Pefmitshall Wicemed revoked.
CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
(�— I hereby afffm that them is a construction lending agency for Performance of 504 - FINAL BUILDING ENERGY
W the de,aNawnirnmispe.it 1,issued Sec.MAD.Co,C.) 505 - FINAL ELECTRICAL
W Q Lendeh Name
a I<nderanddm. 506 - GAS TEST
U O 1 eerily that 1 have read this application and stem that the above information is 507 - FINAL PLUMBING
D. F.,
correct,lagst.comply
,and with
yaucity and countyordinancesof and stem laws relating w
U mow.geonstmcttogand ncmhyanthodvc represemativcs of this ntymemer"Pon the FINAL MECHANICAL
W aBove.menhenedpmprnrrmmapeCo apurposes, 09 FIN
1 (We)agree m save,indemnify and keep harmless the pity of Cupertino ea:inat
fzq liabtlitiews,judgmenu,c"su and expenses which may in any way same alatnsrsaid City 5 Gs
in con.
of
hoodinflof
his promil.
U " APPLICANTtancCUND LRSTANDSIAND WILL COMPLY WITH ALL NON-POINT Issued by:51 WORKS Date v
SO � i
�!/ Re-roars
naw of Ap 'anVCont.ctur Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant stun of handle hazardous material
as defined by the Cupertino Municipal Care.Chapter 9.12,and the Ilealth and Safely
de,section 25532801 All roofs shall be inspected prior to any roofing material being instal d.
❑Yrs
R If a roof is installed without first obtaining an inspection,I agree to emove
Will We upplicum or lumrc building rccupam use equipment nr devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District? , /
Yea /�,yp`
I have mad the hamNous materials requirements untlerChapter 6.95ofthe Califti
ide
equireentsunderChapter6.95oftheCali(m-
nta Health&SWcry Qak.Secuum,2.5.505,2S533 and25534.1 un&rsmnd that E&building
dtsa not currently have a tenant.Nat it is my respumihility to Bed the t>ecupant of the
�y�/s�ts'.Blit 'It cmetPdorwissuamenf.Cenif¢am r a' Signature of Applicant Date
owner¢". bodaca Date- All roof coverings to be Class "B" or better