02010020CI BUILDING
OF SIONNOPERMIT
CONTRACTOR INFORMATION:
DIIVII
BUILDING ADDRESS:
PERMIT NO.
11891 PLACER SPRING CT
DRAEGER CONSTRUCTION INC
02010020
OWNER'S NAME:
APPLICATION SUB DATE
KENISON ALAN R AND VERA M ET
A 605 COMMERCIAL ST
01/04/2002
PHONE:
SANITARY NO. CONTROL NO.
'
(408)536-0420
Z ARCHITEC ANIGINEER:
BUILDING PERMIT INFO
BLDG„ELECT PLUMB MECH
i LICENSED CONTRACI'OR'SDECLARATION
JobDescrip[ ❑
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
° ,angel;orearo)al Division 3onneBa,;n<xxandProfesionxewaanamyranx
RE -SIDING
in full force and dfe
uLicense Class Lic. n
Dim Grollman( -
fn
ARCHITECT DECLARATION
g understand lar plans shall
nae he used , gamed recant,
/
Licensed Professional1.
OWNER -
a. BUILDER DECLARATION
1 hereby .(firm thin 11. exempt License Law for the
the Cssions
reaso Business an
followinguiresa (Section] Co de: Any city or county
Cas
onstrt,at,andve,deoli
D which requires n permit construe, alter, improve, repair any mmcturc
$18237
re h permit t file
. prions i¢ issuance, also requires the applicant for such permit to file a signed star emem
— that he is licensed incident to.do, provixame, of the Conamomfa Liccsx Lw(Chaptar 9
(commencing with Seeiom70001 of Division 3 of the Business. and Profeanons Code)
[ ❑hI9 Or• ea
;^ ":'36,�' \, l ;;
Valuation
or that he is exempt therefrom and the basis for the alleged exemption. Any violation
OlS
„l.1'l:
- of Section ]036.5 by any applicant for a permit subjects the applicant to a civil penally
of not more than eve hundred dollar, ($500),
AIN
NN m�
PditAT
Occupancy Type
101
I ON
° 1, as owner of the progeny, or my employees with wages as their sole compensation,
103 —
Required Inspections
UFER 9
will do the . and the structure 'is'no, intended or iffered'For sale (See. ]aq,
.. Bu,lnc£s and Pmfex,ian, Code: The Cma arose , License Law due, mol apply Io an
owner of property Who builds or improves therm , and who des such work himself
oe though his awn employees, provided Nal such imprammemx are not intended or
-
REBAR ..... _. _ _.... _.
:completion safe. IL however; wibuilding or improvement n ,the within one ild of
completion. me wn<x-atim<rwm have the Women or proving that he ail not baud or
.104 ..
105 —
. .. ..
ANCHOR BOLTS
improve for purposemcile.).
106 -
SEWER & WATER
ring with lic<nxd convactorsm
❑I, as owner of the m progeny. aexclusively contact
202 -
UNDERFLOOR PLUMBING ' '
t . ]M4, Business and Professions CW,) The Commcmr'x
...spun the projec(Sec
uceme Law does ant apply m as owner car property who builds or improve, mares^.
203 -
UNDERFLOOR MECHANICAL
and who.contmces for. such. projects with.. conh.eods) licensed punuanl m the
- Comerctor,LiesoxLaw.
_. _, _ _ ._
204 =
UNDERFLOOR FRAME
❑ l am exempt under Sec. )B&P C for his ..an
205 -
UNDERFLOOR �TNSOLATION
- Owner
301 -
ROUGH PLUMBING
ENS
WORKER'S COMPENSATION ON DECLARATION
`”
302 -
TUB & OR SHOWER
following
Ihereby aretminot, .Penalty arpetipnone afthe falmwiel
303
ROUGH MECHANICAL
0 1 have and will maintain a'Cenificate of Consent to self -insure for Worker's
campemmlom, as proided' for by Section 3700 of the Labor Code, for me
304
ROUGH ELECTRICAL
pem,rmance or the work for which this mid, in issued.,.
305 -
FRAME
° 1 have and will maintain Worker's Compensation Insurance. as required by Section
306 -
HOLDOWNS
3700 f,ha Lab.d Code, for the performance of the work. for which this permit is
i.x. d M WmkeesCompensation lnsa 'erand Policy number am.307
-
INSULATION _,.._.
Policy Ni,.: A�:2x
308..-
SHEETROCK_.
_
„ s ;CERTIFICATION OF EXEMPTION FROM WORKERS '
COMPENSATION INSURANCE" "-
'I I f' 3 0'9 k , z
EXTERIOR'LATH'
_ ._
31.0. -.
INTERIOR LATH c
_t Ghs section need not M completed if the perms for one hundred ars
it id doll
(sl0o)grla,s.)
311 -
SCRATCH COAT
1 cen;fy that n me lice red e f th work for which Nis pcimit is issued' 1
"shall
-<_
31' 3 - -
ROOF NA I li �.- - t
not employ any person ;n any, matter xo ax to beeo,^c snnjtat to he Wmk<r
501 -
FINAL ELECTRICAL ENERGY
Compensation Le—ofC.1iform.. Data
Applicant - - --- -
- - 502---
FI -NAL PLUMBING -ENERGY,--
•NOTICETOAPPLICANTIfaftermaklgd Ccmfca¢ fExemption, you should
at Compcnan p m, ono Lab Coda you mast
become subjeeuo theta_,at"
503 -
FINAL MECHANICAL ENERGY
forthwith comply with such provhmn. or this permit shall be deemed invoked.
_.. _...
--504.-.FINAL-BUILDING-ENERGY
. '"I' '' CONSTRUCTION LENDING AGENCY �-
505 -
FINAL ELECTRICAL..
roe'
yv g agency the pceormeme,
teor`k for this .I,`i:.oad
ofme which ss«°iu97.cf.c)
506
... .__ _._... .... __ .
GAS. TEST. .. ._ _.
Q-Lende'r's Name• . .... .. .__.....,.. ...
L<nder'eAddres.s
_ .r.
507 -
.. . . .. ...........__
FINAL PLUMBFNG;,.`
z
1 comity that 1 have read this application mal t,,, Inst Ne ahove information is
508 -
FINAL MECHANICAL
comert. 1 agree to comply with all city and county ordinances and state law, misting
5 0 9 -
FINAL GRADE
ii to building construction. and hereby authorize representatives of this city to enter upon
�0 meibove-mendpoedpmpertyfornr sda.pamo,rx._
510 -
FINAL PLANNING
y (We l agree 1.save, indemnify and keep harmless the City of Cupertino agaimt
R
a liabilities, judgment,. cons and expense, which may in any way a«me against said
Z f,ha ",.
514 -
FINAL Lj$
crym consequence gmmingol this permit.
'APPLICAS-L UNDERSTANDS AND WILL COSIPLYWITHALCNON-IxilxT4'
i/—�
Ii
^
SOURCE REGULATIONS. ,
Issued by:
Date
_
Re -roofs/
'
Sign atare.fAppIieam/Cmareamr Date
HAZARDOUS MATERIALS Da c 6, URL
W IIytimeC 4 t t b ted g up t co handle bard x
....Type of Roof.
.. _ .. ..._ ... ...- ._-........_..�.. _..
Safety
a Jf d n 25Cup t Municipal C Chapter912 and the Health and Safety
L'Odf j ye 2$53-r 1 i1. D 1 7 -
°rex'"' IIIAAAIINVV ';
' ...
1. \..• t ' .. \' -
roofing materlal,being installed._,
_
All roofs shall.be,mspected
pnor.tolany
a Will the applicant or future build g p laxro pmentorde ices which
If a roof is installed without first obtaining an inspection; I agree to remove
mu haams1m%air< I t sJcf" by th Boy Area A O'fry hfmagement
Dinrml
all new materials
for inspection. Applicant understands and will comply with
e N°
Yes,
all non -point source'
regulations..
" 1 have read the hazardous mnerials requitemcntsunda, Chaprer 6.95 of the
California H<ehh&Safety Coal. Section,25505,25533 aIle 25534. 1 understand that
-
inhebuildmildae,emementlyleve atenankthalill, mym,p°nsihilitymnmiry the
-
,f the re miremems w'hieh must W met prior to issuance of a Certificate of
°" ,/)
/Data
Signature of Applicant Date
Mge^t D'
_
All roof coverings to be Class "B" or better
Data
Drr
�r
or agthonz gem
ap-thhonz
OFFICE _.