02100033 CITY OF CUPERTINO _"wa I "^• °*-- "' ••rt
BUILDING DIVISION PERMIT CONTRACTORJNFORMATION.1'
BUILT c I@ESPENDERGAST AVE ADRIENNE HARBER PFRMIFNC2100033
AOR110ENNE HARBER 18900 PENDERGAST AVE APPUCATI(pl�l/P/NIr1E2002
ZONE: SANITARY NO. // �� / CONTROL.NO.
ARCIIITICCIOENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MliCll
0 0 0 0
0OO LICENSED CONIItACfOR'S DECLARATION
V_ 1 nerebr arum that 1 am hun.kd ender provisions or chair',9 mommmeing ADD GARAGE�� es�t'j�ption
rn<iwith Section 70gl)of Division 3 of the Business and Pndcaxaes Codc,and my license is
in full force and efful.
�d Z��= Limmecl'acv Lic.N
— Dale Conomob
F=� ARCHITECPS DECLARATION NOV 1 8 2002
C 1 undershind my pDox shall M used m Public mord,,
a;a3
oia. Licensadl'rnfcxsiumd R
Fu'O�
OWNER-BUILDER DECLARATION
Contractor's
ontr ON BUILDING 6500
K£ 00 1 hereby reaso allium tM I 1 am cxcmpt from the Cssions Cur Licence Law Int the
m—pO which requires
emits 7onstru Busmen. and approve,
demolish.
Curb Any Guy or county Y
n'K m� which rcquims a feast re comas the alter,i applicant for su h sunlit t nr repair any atrucWm
1O—" pdnnni¢censedaomalso rt to he thovisis(if for compactor's Licenfile ase
aw(d Ibtemcm
SL't: hemhcisliccnsed Dursuant to he of Distorts of thecontractor'srmr'xnicer Law(Chape)9 3 5F3�.eA32A10A Valuation
n'�� thathemhe is exemitM1 Section Oland of basisfor in the al Bueinexe piond n.Any vi Code)or
i 3� that he is eacmDl therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of UAPrtN9@WF=iUN Occupancy Type
not more than f�vehundred dollars(S500f 102 - PIERS
I�Jf/t 1 ae owner of the properly or my employees with wages as their ante mntpensation.
wiB Jo do work,and flax slrvcmrt is rat intended or offered for sale(Sm.704L Business RC uired Inspections
and Professions Code:The Contrzmor's License Law does not apply m an owner of 104 - REBAR 9 p
propcny who builds or improves thereon,and who does such work himsel for through his
Own employees.provided that such improvements am not intended or offered for We.If. 105 — ANCHOR BOLTS
however.the building or improvement is sold within one year of completion,the owner- 106 — SEWER & WATER
builder will have the burden of proving that he did not bund at improve for purpose of
sale.). 202 - UNDERFLOOR PLUMBING
E] 1,as cavort Of property,am exclusively contracting with licensed contraaom to 203 - UNDERFLOOR MECHANICAL
construct the project(Sec 70,14.Buxlnese and Prul'cannon Code:)The Contractor's Li.
wasom Law does not apply toanOwner OfPTONrtywhoWilds orimproves lheeoa.add. 204 - UNDERFLOOR FRAME
who contacts for such poppers with a contnam(s)licensed pursuant o the Cotnnctms 205 - UNDERFLOOR INSULATION
License l.ew.
I am exempt ugder SeeJ This reason
, 301 - ROUGH PLUMBING
nrrW44 i -..., o _ Date 302 - TUB & OR SHOWER
WOKE ': 0P:NAION OPELRATION 303 - ROUGH MECHANICAL
Iherebyaction under Penalty ofNippy one ofthe following duHrabons: 304 - ROUGH ELECTRICAL
I have and will maintain o Certi reale of Consul to sel6imue far War C..K..
-adim,az provided for by Section 3700 of the IaMv Code.on the performance of the 3 0 5 - FRAME
work far which this p.if isissued. 306 - HOLDOWNS
❑1 have and will maintain Worker's Compensation Insurance,ax required by Scnioo 3 0 7 - INSULATION
3)10 of the labor Code,for the performance of the work for which this permit is Word
My Worker's Cosipcwtion Insurance carrier and Policy number ase: 308 — SHEETROCK
Carrier: Policy No.: 309 - EXTERIOR LATH
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 310 - INTERIOR LATH
minsscction necicol hccompletedifthelerinh isfornnc hundred dollars(SUM) 311 - SCRATCH COAT
orlcxx.) 313 - ROOF NAIL
1unify that mme pe,fmmanu of he won for which this permit is issued.I stall not 501 - FINAL ELECTRICAL ENERGY
employ any permn in any man uas mhcpnt_11 rUu nIhe Wow.
Cnm n
Lawsofcalt r a. me - W 502 - FINAL PLUMBING ENERGY
APPlicant
l7rICET A ICA :If.after making lhol Ciao rrateo!E10!bqadn,ynushnuld 503 - FINAL MECHANICAL ENERGY
bccnme_subjecun the Worker's Qinfamminn provision.,of the"hot Code,you must 504 - FINAL BUILDING ENERGY
z forthwith comply with such provisions or this permit shall M deemed revoked.
z0505 — FINAL ELECTRICAL
CONSTRUCTION LENDING AGENCY
(�. .�. Thereby allium that Iniert itvs a ond
cmction lending agency Inr the perinrmanes•of 506 — GAS TEST
a > do,work In,which this Permit Isissued(See 31N7.Civ.C.) 507 - FINAL PLUMBING
5zWO Lender'sAame 508 - FINAL MECHANICAL
Lender's Address
U O 1 unify that I have read this application and shire that the above information is 509 - FINAL GRADE
correct.1 a res to comply with all cit and count Ordinances and state laws rcland to
OU buildingconstmction. and hereby aulhorimrepresentatives of(his City toenter upon the 5 FINAL PLANNING
>" w above-mentioned property ser Inspection purposes. 14 FIN LIW RKS
(We)agree m sacs,indemnify and keep hmmless the City of Cupertino against 1
L.
N liabilities.judgments.costs and expenses which may in any way accrue against said city O
CJZin nvqucncc of the granting of this farm it.
APP (CANT UNDERSTANDS D WI L COMPLY WITH LL NON-POINT Issued by: Date
SOyCP EGUf.ATIONS. /y
9 SA lgqdiI$�- / L. mac/ 0•f' Re-roofs
4DixtricC
Tumo n�caoUcantmeI& Date
HAZARDOU S MATERIALS DISCLOSU RE Type of Roof
Will the applicant or future building Occupant store or handle hvafdous material
dclincd by the Cupertino Municipal Code.Chapter 9.12,and the[health and Safety
A..Seebon255u(a7 ��`/// All roofs shall be inspected prior to any roofing material being installed.
�Ycs ICI N`r
will the applicant or Iumre building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
it ha m roue air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
❑Vas 10
1 have renal the harardous materials myuimmcnte under Chapter 6.95 of the Califon
or.llcalth h Safety Cafe.Sections 25915,25533 and 255U.1 understand Nal if the Wilding
dues nal currently have a tenam.Nal I,i.,my rexrymaraI Iy�ty the Iecupwl of the
mq me." s<eaneofacenir tend 7=y. Signature of Applicant Date
0.- YLL1.Q<l'In'1.L.�'�' ---Z_(d�—IN� 2 All roof coverings to be Class "B" or better
Own nr authh( i dagcm