02110024 CITY OF CUPFirt-INO
BUILDING DIVISION PERMIT CONTRACTOR,INFO RM ATION:
BURBI&EAIDRIPARK VILLA CL PERMITNT2110024
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owbRA&TSnH CHIRMADE j APPLICArB1N1SVu3i`4T02002
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orIONB: SANITARY NO, / 11 / CONTROL NO.
�ARCHITECT/ENGINEER: Oit w'�tJ� IL ITINFO
LUMB MECH
0 0 0 0
wp�0 LICENSEDCONTRACTOR'S DECLARATION p [ QOO
s�F I bercby affirm that l am licensed under provisions of Chapter 91a,mmcncing SOLAR TUBE SK`�o�,lrUg 'j��onApR 1 J L
aZw with Senion7(XXBoflllvision3aflhc BusinexsxnJPndcsxions Code,anJ mylivenm is
r^ ^• in full fraw,and effect.
�z z Litre,
Class Lim. BUILDING
O —o Date im.# or
ARCIIITBCT'S DECLARATION
ads�a I unJcrsmnJ my plans snail be used as politic records '
Co `D
a. Licensed Professional
)-a an OWNERBUILDER DECLARATION
2 1 hereby from'hat 1 am exempt from the Contract s Lice..Lawl lin the $1000
its o O fallowing re a.(Section 7031,5.Business and Professions Code;Any city or county
e
022 which requir a permit to construe',altcr.improve,demolish,or repair any structure
"l�'r+ poor it)its issuance.also requires the applicant for such Permit o file a signed statement
that he is licensed pumuanno me posolonsol'he Commclnfs Lomme Law(Cadre,9 33 6FB.�,dA1U Valuation
Ott$ (commencing with Section 7000)(if Division 3 of the Business and Professions Code)ar
y that he is exempt therefrom and the basis for me alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to acivil Penalty of PN-N Occupancy Type
no'more than five hundred dollars(SSq). 102 — PIERS
❑ I.as owner of the property,or my employees with wages is their Sale compensation,
will do the work,and the abortion,is not intended or offered for sale(Scc.7(414.Business
and Profession.Code:Tae Common's Lluenset Use does not apply to an owner of 104 - REBAR Required Inspections
property who builds or improves thereon.and wan does such work himself or drought his
own empleyces,provided that such imprmsmcnts are not intended or offered for sale.¢ 105 — ANCHOR BOLTS
however,the budding of improvement is sold within oat year of completion.the owner 106 — SEWER & WATER
budder will have the burden of proving that he did not Wild or impress for propose,i of
sale.). 202 - UNDERFLOOR PLUMBING
KI.
es owner of the property,am exclusively conincting with Iianaed contraemrs to 2 03 - UNDERFLOOR MECHANICAL
C m"Lr the pmjcat(Sec.Amo,Business and Professions Code:)The Confi ire's Li-
,. c, awdoesa,, Fly morvererofPmperrywho Wilds orimproves thereon.and,
204 - UNDERFLOOR FRAME
who contracts for such projects with is marichr(s)licensed pursuant to the Contractor's 205 - UNDERFLOOR INSULATIONLicense Law.
❑ Ia n1rndersec. B&PCfor lldlmaa. 301 - ROUGH PLUMBING
ugh Cti1YvNODaw 04 ll ib')— 302 - TUB & OR SHOWER
WORKER'S COMPENSATION DECLARATION ill 303 - ROUGH MECHANICAL
I hereby affirm rout,peaahy of pe do,tun,of me m)Dwmg declaratii is: 304 - ROUGH ELECTRICAL
I have and will maintain a Certifies.of conscntt r_1
the B.Workcrs,Clnmpen 305 - FRAME
cation,as provided for by Sectio 3700 of'ae laver Cub,for me ptrfnrmaoce of me
work for which this Permit is issued. 306 - HOLDOWNS
❑1 have and will maintain Worker's Compensation Insuranceas required hytSeetion 3 0 7 - INSULATION
37q)of me lava,Code,for the perfmmanee of me work for which this Permit is issued.
My Worker's Compensation Insurance carrier and Policy number are: 308 - SHEETROCK
Carric,: Policy No, 309 - EXTERIOR LATH
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 310 — INTERIOR LATH
(Thisxec'ionnedd notbe CDmplcmd ifac permit isforoncaundreddollars(SIOO 311 - SCRATCH COAT
less.) 313 - ROOF NAIL '
1 ccnify matin the ,frm,ance of the work for which this Permit is issued.1 snail tut 501 - FINAL ELECTRICAL ENERGY
employ any anymanner ,as l come hjeetbuhe Workers Compensation
Lawsaf CaliR,mis l)pre t�9�t ^' 502 - FINAL PLUMBING ENERGY
Applicant AP I1Cs �cter mi1'�
NOT GTO AP LICANI':B,aftcrmaking his Ccnifica¢nfExemption,you should 503 - FINAL MECHANICAL ENERGY
OvyiWesubject'o the Worker's Compensation provisions of'he Labor Code,you mus 504 - FINAL BUILDING ENERGY
Z, forthwith comply with such provisions or this Permit shall he dmmcd revoked.'
Oz O 505 - FINAL ELECTRICAL
CONSTRUCTION LENDING AGENCY
F.t Ian n,erenyaffirm met there isaconswtoonlending agency(or the ptrra;lanco'if 506 - GAS TEST '
C. > the work for which this Permit isissued(Sec.3097.Cie.C.) 507 - FINAL PLUMBING
W 0 Leader',Name
a. Ureter'sAdd.. 508 - FINAL MECHANICAL
V O 1 aniry that I have read mis application and Stan,ma'the above intrnmmh,e is 509 — FINAL GRADE
W (-. correct.l agree to comply with all city and county ordinances andsale laws relining to
DU building construction,and hereby autharimrepresentatives ofINS city menter upon the 5 FINAL PLANNING
} W anon conn) ned agreetoSawfmcomilyian keep
ta 14 FIN I W RKS
W (Wc)agree to save,indemnify and keep harmless the Clry of Cuperti 11 against
rrn liabilities.judgments,Costs and expenses which may in any way see=against sad City G(//
U in crad.,ri oft he granting of this permit i
r. APPL CANT UNDERSTANDS AND WILL COMPLY Willi ALL NON-POINT Issued by: Date
SO .F EGULAf10 _—Zfl1 (0
Re-roofs
Si
HAZARDOUS
Udt
torforum Mding occupant
DISCLOSURE til Type Of ROOF
Will the applicant or future building onnupan'smre or handle harerJous material
as defined by the Cupertino Municipal Code.Chapter 9.17,and the[Icahn said Safety
Code.Section 25532(x)7 �'I All roofs shall be inspected prior to any roofing material being installed,
❑Yes No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant m m'me nDimlog rctupant use equipment or devices which i
emit hararJnus airaontaminanu a'dclincJ by the Bay Arca Air Qoo111y Management all new materials for inspection.
District
❑Yes �No
I have read he hamNousmuterials requirements under Chip CT6,95 of me Calif a-
nis Ncalth&Safety Ctdc.Sa:tions75505,25533 and 25534.1 unolctsuml that if Ihc'Ituiding 1
does for Currently have a tered,hurt is my ne"milahly m notity the"Cape at of me
requiecyte%}t yhicjmust Ct prior m issuance ofa CcmOcatai-agppancX k� Date
1��`/'/ �,rSJt),pT"'- ,"'�p.� Signature of Applicant
ownmm mod,tdagen, `seryl All roof coverings to be Class "B" or better
ARCHITECTURAL APPLICATZN
Name ofussouatauon: �� S} Yri0 rl} !��>/k -
evu-iru'a nicer _ �I�
IN M rnnnNr,F ATH TNF r•ITY Ofi Qp�es Hl Zvi lzu el4-mA CN IRM AW,521 F PnpoICUPER'INUamu o' FtOk'�tvANCES U�1TEA� ,rPA(RiC VILLA �+� _ VVL ��`ri���_ �a�sa��i�
SIGNED_ W tsar 6 Sgt^ S i n Home Phone: °8 77 7. 8 7 I _
This set ( f til, and soecifications MUS!
be�wfulpto l times and it ic un
Appkpu�t:,igrees.�and,utidasnnds that the application does not fulfill all of the conditions and requirements for an ap-
proval. Tn addtrion io tits completed "Architecaual Application" form, the applicant must submit 10 the Architectural
on same tlteGieavtCattimsi ct(�n°d/o�Board of Direaors)a set of plans and specifications showing the nature,kind, shape height,
the buildin=fer'inlsraa`d 1'oc$aun"s'ofthe proposed archirectutal alrcmdon. It is also understood by the applicant that the submis-
The stamp i8ritmuit"SP iiP r ria'fig It—_ 'ere tray be additional information required as deemed necessary to make a decision. Until
SHALL NOallitiW6L5tioanu fiibitsitfedrto the committee, the application will be deemed to be incomplete and the application will
approval Q'siinduilippr&edy provision
env ritvG ^ LtDESC a EMO�N OF PROPOSED WORK XNCLUDE DRAWINGS,IF APPAO1PRUT�E)
vt(P t, b-C.,(�_ rf -L i""(1 1'Fr'O SL^'j L5N.lS bN S� r .'Iwx,.. O,^
J= !�j C;h. _ 3 w.7 ov. {ems ..{ s i Mors bets) "yVj
tet. -s 1 k7 G-t ./ ,f:�
civ. ru�n�--� .+r lo.Y - �`° P �C �-t^'.
i5 l;Lto A#. %l-'t InS'4t if Wt II N. 4A f-t.o l0i.,.
qr.e f He CQ wc.0 GKJ4"1 w`1.1-\ a-o�/ cI-
Applicant agrees and understands that, in the even rhe modification is approved by the Committee or Board,that they
may impose "Special Conditions" of construction and maintenance on the approved work. Any special Conditions shall
be. attached and be a part of the approval. Any deviation Rom the approved plans, specifications or special Conditions
Shall cause the permit to terminate and become null and void. Applicant agrees and tmderst Inds that failure to conform
to these requirements will be automatic authorization by the replicant to have the work brought into confotmaace with
the aFproved plans, specifications. and special conditions. Applicant ftrrther agrees and understands that all costs in-
cuffed by the Association as a result of bringing said work into compliance shall be a charge against The owner's lot.
Such costs shall iaclude costs of cou�trucdoa, reconstruction, administration, feu, aetcmey fees and reasonable court
costs, if incurred. It is also agreed that no work vnll be initiated which would be a violation of any of the provisions of
the Association's Declaration of Covenants.Conditions, and ieesoiwons or any applicable building code;be as annoy-
ance to the residents, or increase the cost of insurance. Applicant agrees to indemnify the Association against any and
all acts or claims arising in Connection with the improvement,including but not limited to any and all acts,omissions,or
claims arising in connection with rbc approval; construction. operation, maintenance, repair,use or removal of the im-
provem:nt. including attorney fees and costs of litigation in connection therewith. Applicant agrees that, in the event
the application is approved,all maintenance, repair or replacement of the approved iters will be the sole responstbikiry of
the unit owner and further that any expense incurred by the Association that is the direct or indirect result of the ap-
proved Change shall also be the sole responsibility of the unit owner. Alt work sbowd be initiated with consideration of
the grounds,esthetics.time and noise factors. Applicant understands that all necessary pettaiu and approvals from mu-
nicipalities or other jurisdictions are the We responsibility,of applicant and that Committee/Board approval of this ap-
plication is Subject to the applicant receiving all such nCCg5Sary permits and approvals.
Applicant agrees t e fortgo!Lngcond5aapAdffi as a%idenced by the owner's
elL5Date: IO 2 ¢ /c z-
002
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