02030129 CITY OF CUPERTINO
BUILDING DIVISION PERMI CONTRACTOR INFORMATIO•
BUILDING ADDRESS: PERMIT NO.
10205 POTTERS HATCH CMN CUSTOM KITCHENS & BATHS 02030129
OWNER'S NAME: APPLICATION SUB DATE
FRIDAY KAREN J 581 CALPELLA DR 03/21/2002
PHONE:
i (408) 829-0078 SANITARY N0. CONTROL NO.
{9sf O O ARCHITECr/ENGINEER: BUILDING PERMIT INFO
z F. BLDG ELECT PLUMB MECH
`uf
j I� C� C.-1 I_)
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Z LICENSED CONTRACnderp DECLARATION Job Description
Z_ 1 hereby affirm that l am licensed under provisions of Chapter 9lcomnencin¢ P
„t� whnsecedr7no>drDisiann3anneeusmesarapmfasidnaCode,an my license REPLAC.E_��F�IXTURES/WALL COVERINGS .
i m m is in full force and effq1 / (-� B' TffRMS)
5 m0 m License Class 17 Lic.a 1 t1 l•1���B L Y�
a O� Data�,_- t��� S DECar f�q �:
A HITECT'S DECLARA Y
to
g1 understand for Plana anon be,used as panic records ��L g 0 2002
5 25 O O Licensed Professional
s�R OWNER BUILDER DECLARATION
I hereby aR1m that 1 am exempt from the Conlranor's License law for the p1N�
C Z< following mason,(Section 7031 s,Business and Professions Code:Any city or coumy
F❑
which requires a permit m eanawn,dale,improve,demolish.or repan any swcmre BUIL
i3$ .pnomoiuissuance.also requires the npplicant for such pamit to file a signed summon, _
- thathe,iBJacerts{dpursuant to the pmsyskarxofhoContractors License Law(Chapter 9 Sq.-Ft:Floor Area,-,. - Valuation
(commencing with Section 7000)of Division 3 of the Business and Professions Code)
or that fits is exempt crercfmm'and the basis for the alleged aamytibn.Any violation - •' "' `
-of Smite 7031.5 by arty applicam for. .is subjects rhe applicant to a milm
pahy �Nh s `
of not more then five hundred dollars(x50% umber Occupancy Type
Ol,asdwnorofthepmpeny,ormy employees with wage,.s,h,i...le compensation. _
will do the work,and the structure is not intended or offered for sale(Sec.7003,
'Business and professions Code:The Commetur's License Law does not apply to an 102 - PIERS Required Inspections
owner of property Who builds or improves thereon,and who does such work himself
or through his own employees.provided that such improvements mens arc not ism yea of 103 - UFER
offered Tor role,w howtilde w l have t or improvement n sold within not Yah dr -
companion,the ownenbuilduwinhaveteebuNenofpovin¢that hedid nmb�neor 104 - REBAR "
improve for Purpose of sam.)' 105 - ANCHOR BOLTS
❑Las ownerof herojec property,oro Business
mromssionslicensed e Contractor
106 - SEWER & WATER
LicenseLaw project
apply ten owner of propeny who builds or imodi proves thereon, 202 - UNDERFLOOR PLUMBING
and wbo contracts for.such prejects.with a contmcter(s).licenael pmadai to the
Contaence.LicenseLow. 203 - UNDERFLOOR' MECHANICAL
❑I am ucmpt under Sec. B&P C for this rtnon 204 - UNDERFLOOR' FRAME'
Owneri Dat` •' 205 - UNDERFLOOR INSULATION
WORICER'S COMPENSATION DECLARATION 301 - ROUGH PLUMBING
I hereby affirm under penalty or perjury one ohne following declarations: 302 - TUB & OR SHOWER
(� ❑ and will maintain a Certificate of consent to seleirsum for worker. 303 - ROUGH MECHANICAL
1• ompcnsa)ion, as provided for by Section 3700 of the labor Code, for the
Ixrromlan<e ar the work for widen this permit is issued. 304 - ROUGH ELECTRICAL
CAa'� 4k/ 305 - FRAME
issued. orker'sco y 306 - H L OWNS
have and will mainuin Worker's Compensation Insurance,as sequined by Section
r me performance of me work for which this permit is
,nsktion lnsumnce cooler ens Polic number are:
a t e Labor oda. °_.. ._ __..-.. . . .:....
Cvrier. ru)/�r/1y/.n °Bcy'Na.: f� 307 - INSULATION -I .. . . . - .. . . .. .. . _
tcERnP7 A ONOF EMPrIONFROM'WOR - - ' ` c 1308 '-SHEETROCK' ; "
-' COMPENSATION INSURANCE'• • i.
----'309 -= EXTERIOR-LATH __;.__. .. .....___. ..._.. _-- . . . ._
Cnfaumiohnecd adobe completed if the pcmtit is for one hundred dollars 310 - INTERIOR LATH
(3100)or lersJ
I'terufj that i-`m*pnrlf.rm.`ro,_,cJ`,hc Work for which,his .it I is.issued.1 311' - SCRATCH :COAT... .." ., - - . . •.....
•shall not employ any person in any manner so as to become subject to the Workna313 - ROOF NAIL'' '
Compcosmidn Luwf of Califomia.Dme' "
Applicant 501 -FINAL -ELECTRICAL ENERGY..- _-
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should
z bel°mesubject,othe Worker's Compensation provisions of die,Latest Code,you must 502 - FINAL PLUMBING ENERGY
X70,0 forthwith comply with such Provisions or this Permit shall be dimmed revoked. - 503 - .FINAL MECHANICAL ENERGY _
,n
_t "' - "'CONSTRUCTION LENDING AGENCY '
F drm�wmkforwdedthin them
mist •. 504 - FINAL BUILDING ENERGY'
I hekb which this cmut is ismswcuon 3091 g Performance
-
y ndin agency for me peRo ,
a r aeaw(sec.3o .m.c.) 505 FINAL ELECTRICAL
LLQ -Lenders Name...... ... _... .. . . .. .. ... _
--az LeuaertAaarzxs - 506 - GAS TEST
0:0 . 1 certify rhos 1 have mad this application and nam that the above information is 507 - FINAL PLUMBING
z' Garect I ogre w comply win ail city and county ordinances and state laws relating 508 - FINAL MECHANICAL
=0- the above-mentioned
uposentativci of this citymenmr upon
W rot aba(We)agree
prop rty for ify an inspection pafppse509 - FINAL GRADE
Pr c es,j agree to save,indemnify and keep harmless yin me Cily of eme agai against
'�.y liabilities,judgments,emu and expenses which may in any way,eccme against said 510 - FINAL P I NG
U.z City in consequence of me grmting.of this Permit.. "' ' -' Q
APPL DERSTAN DWILLCOMPLY'ATTHALLNON-POINT' r,14 N WORKS /
x
g � O2 Issued[Sy: Date 7—
Si f A'p can✓Cont las .••r -Dam ' Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
wllmcappli=t'mfoluribjdingoccuputitomwhmd)ehai.i ,rnmmstedal Type of Roof . . .. ..
u J<Gned X by the Cupenino Municipal,Codc,Chep,a 9.12.and the Health and Safety r, - -
Cd4.Secrion255J2U1 s ,-T - r `• ''�Y"•- `•'°�:• { ' a _ All to shall be Inspectt;d_pnor to any,roofing material being installed.
Win the applicant or fuurt buildingompant use cquipnrcnr or devices which If a roof is installed without first obtaining an inspection', I'agree to remove
X emit harardous an contaminants as defined by he Bay Arca Air Quality Management
Discoed all new materials for inspection. Applicant understands and will comply.with
all non-'point source'regulations."
1( I have read me hazardous mpter
aterial%mquiroments boder Cha '5.0'of the
Califomia Hcalth&Safety Code,Stertors 25505.25533 and 25534.1 understand that
if me building does no,cu minty hove a minor,that it is my rtspmsibili,y 10 notify the
n
In, the tri ots which bt;md poor us issuapce ora Certificate of
-�Z Signature of Applicant _ Date
�t Ownerm mor g fic ' b All roof coverings to be Class "B"or better
I .. -..-:.._ .. .. OFFICE ... . . . . . . .
ZIP
CITY OF CUPERTINO 0203 d/zl
PERMIT APPLICATION FORM
CUPERTINO
APN# Date:
Building Address:
(! LKXMv
Owner' Name: Phone#:
7 '_ 3
Contrac r: License#:
Contact: Phone#: b G ��
;�j G� Z O
Applicant/Contractor, Fax#:
L- b Rle-C-5
Building Permit Info:
Bldg Elect Plumb Mech
Job Description:
Residential: Commercial:
Sq.Ft. Floor Area:\' $/Sq.Ft.:
/K 2— S
Architect/Engineer: Valuaton: /D t
Type of Construction: Occupanc
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILER1 Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi, BUILDING
BCONSTA)MQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V<= 1000A ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC I Comm. Housing Mit. Fee BUILDING
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OF
CI BUILDING DIVISION ERMIT
� CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10205 POTTERS HATCH CMN CUSTOM KITCHENS & BATHS 02030129
OW NF.R•S NAME: APPLICATION SUB DATE
FRIDAY KAREN J 581 CALPELLA DR 03/21/2002
`HONE: SANITARY NO. CONTROL NO.
s (408) 829-0078
... ARCHITECT/ENGINEER: BUILDING PERMIT INFO
g BLDG ELECT PLUMB MECH
C:=1 L__I
,8 '—o LICENSED CONTRACTOR'5 DECLARATION
NI hereby.than that 1 nm licensed pude,pmasiaas archapter 9(commenting Job Description
„F y with SectionN00)ofDivixion3onheBusine andPofenionsCod<.an en, Nanse REPLACE FIXTURES/WALL CCOVERINGS .
�m$,� is in fell fm¢e and eff _ INALED
S O W uamse clan, i� (2 BATHRMS)
Data�_�_�� Commctn
• a,ti J " "AlIC111TECf'S DECLARA
e g 1 oudemmna my prom surest the area as vunue,ecadx J U L 2 4 2002
2ta_a p O Li<enud Pmfcxxional
o OWNER-BUILDER DECLARATION
i1 hereby union that 1 am exempt from the Contractor's License Law for the
—afollowing mason.(Section 703 1 t,Business and Profevoons Gdc Any city or county
o BUILD_ I _
which requires a permit to construct.altar,improve, re
ve,demolish,or pair any swm ctu
63� ..prior m ice issuance,also requires me applicant for such Porrino file a signed statement ___.
mmhe,irh«nxdpummenttothea,bvWcn.unheContractorsLicenseLaw(Ch:mir9 . S Ft:}F1oorArea ., :,., , Valuation
(commencing with Section 7")of Division 3°f the Busineuand Professions Code)
�ti;+,•9�- try„'B
.,that he is eumpt theiefrom anJ the basis for the allegeA dcmyiori.Any violation '
of Section 7031'.5 by any applicant on a permit subjects the applicant to a civil penalty
'.l..,ltanfive hundred dollar,S5tgp. umber Occupancy Type
❑1,m marer of the pImper y,or my employees with wages as Meir sole compensation,
will do the'w°rk,and the strt«mrc is our intended or ofrer[a'fr,sale(Sec:7014.- Required Inspections
Bpamesx aad Prokoinm Law The C.mourlars License w does not apply m as 102 — PIERS .'
owner of propeny Who builds or improves thereon,and who does such son himxelr
or doomgh h'. empty p od-mi n improvements are not intended or 103 — UFER.__
.offe df .'le If-n o tl' n Id g pni sola wenn one rmr of. . _. ._ _ .__._._ _ .- _._ .__ _ _ s .... ........ .. _ ..__... .. _.
completion the owner-builder will have the burden of proving that held not bold or 104 — REBAR
improve for purpose of"o.). 105 - ANCHOR BOLTS
17La:cowner't;r[lie property,.7m.asclusively ProfesngwaCoil Thcammaurxm 106 — SEWER & WATER
- _ onswatheoesno(Sec,7toanowneroandPrtywhosilde:)TheComano,s 202 - UNDERFLOOR PLUMBING
- -
License Law dos not apply to an owner of pmpcnY who Wilda a impmva thereon, '
anawho.cuntmctsJor-such pmjects.wim a contmetoru).licensed paramour to.the ....._-._. .2'03-- UNDERFLOOR'.MECHANICAL ---- - -
Cmuraror,s License Law.
❑I am exempt under Sec. ",B&PCfrrlhis.vrmn 204 - UNDERFLOOR"FRAME."
Owner' ' '`'Date 205 - UNDERFLOOR INSULATION
'WORKER'S COM DECLARATION 301 — ROUGH PLUMBING
lnercby alum pray Penalty of pcijuryoncoftherollasving declarations: 302 — TUB & OR SHOWER
❑ 1 have and will maintain a Cenificatebf Cmired'to rev-in...c for Workers 303 - ROUGH MECHANICAL
'f�+7 Compensation, as Provided for by Section 3700 of the labor Code. for the
perrarmana anW work rarwmch mix,M,me ix ixmpd' 304 - ROUGH ELECTRICAL
h d willriainm Worker's C pc Insurance.azroptredbySection 305 - FRAME
y' or mewW. cwe for the perm e rate work for which this Permit is 306 - HOLDOWNS
/\ Cao d rk r s Cn e t n I . u lid Pol cy robe e.,,_,i
xs 3'0,7x.`- :INSULATION. .
m<r s" lie "a
CFRTIM A ION OF EMPrION FROM'WORKERS` ' t a 1
—COMPENSATION INSURANCE'_ - �• 3 01
B ' JSHEETROCK• ' •`
. _..,.,___309•:= EXTERIOR .LATH
f1M1 s uaron need not be completed if the permit is for one hundred dollars 1 j., '
(aPgol or less.) 310 - INTERIOR LATH
riirytht rim perm. . eorNeworkf n hln pe ' tis 1'.7's: a;i '311` _ -SCRATCH COAT - "' '-.. ..'..' ••. '.....`
con not employ
y Person
it o as to become subject to the Workers313 - ROOF NAI L
n o Lir mpnn r lc '
p so, Date -
AppPdant - -50-1-----FINAL--ELECTRICAL -ENERGY.._ ....._...
NOrICE TO APPLICANT If B making thisCmificate or Exemption.youmind s +
z bac°mesubje<tl°theN'orkersCnmpcnsotionpmvisions°fm<tab°rCdlc,you must 502 - FINAL PLUMBING ENERGY
Q Q forthwith comply with,ouch provisions lir mix pemsit>hull be Jeemea revoked. 5 0 3 .—.
_ _ _ _ - -FINAL MECHANICAL ENERGY,. - ;....
'm t - 'YDN§raucrloNLeNDmcncENCY 504 — FINAL BUILDING ENERGY.,..,',""
I heichy fri m ihatthe .t et on lendin agency for the performance
" ' _505 — FINAL ELECTRICAL
of th' rkf r' hc6 thsp'nu 97; iv.0 '
a(S i0
zLend r Name .. "- - TEST ae .
Lnr Aaar 506 GAS TEST t
UO 1 nfym rlM1rcedthrsapplict nJst mthm thcaW ' f otos 507 - FINAL PLUMBING
mrmc, I agree m comply with all city aha cards,Amman«s a state laws relating 508 - FINAL MECHANICAL
.Q W tto he bam-m,mm.pion,and nerchy,pocti mrcprmenmtiy<s of This city menu,upon
T 11„;w the en(We)agree
nee of save,pm,Ifty fpr inspection p bumug, 509 — FINAL GRADE
a (We) g ms a detrmfac dkeep hihama ss the Cdyofcrue a against
E'-lin liabilities.judgments, s ore x res which may any r against m 510 — FINAL,PL I NG
U,XJ City . q vc of the granting fm: pe t 14 (� N WORKS
APP` 4NTINDENSTAN hD WILL COMPLY WITH ALLNONPOINT''
see R Ice �� OZ Issued y: Date ^L
X , Sis., . rnp c mCm D« . Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
•.r wn the apphsant a rowre W 3e ng ottvpanut hartdlc nazvdo s metrial Type of Roof .. .. _.... _ . . ... _ _ .
as defined by theC pen c Muni c pal CM Chapter 9.12.and the Health and Safety .. -
X od ❑Yc 255n2(al s l1. a s 4} u,
_ �• :;• ,. ;„ ;_,- --__All roofs shall,be,mspected prior tri any.roofing material being installed. _. ._
theappl', r fur ren Id'ng occupant t use equipment w
nt n devicesMch If a roof is installed without first obtaining an inspection',I`agree to remove
win
nth d 'r ma t'n ti fined by the Bay Are.A is Q al ty Management
Dist ct all new materials for inspection. Applicant understands and will comply with
(� °Y �4-"°;- 'r all non=point•sotirce regulations. - -
'4� 1 hava ml the hazardous matMnls rcgmrements'unJbr Chaptar 695'of the
California Health&Safety Cale,Sections 25505.25533 and 25534.1 understand that
ifthebild' gJ tcurrently have a« tthat ts yropo bltyt -tifythi
occupy t the t 'h b y he m<t p t rxs 9 f C n Bc rt of
It Dec:p ��,. 3%2� .. _ _
Signature of Applicant Date
E ownerar Datq,, All roof coverings to be Class"B" or better .
.OFFICE