02030101 [OWNER'S
ITY OF CUPERTINO ' -"' Tz - ' = t' " e -1
BUILDING DIVISION PERMIT °"CONTBACTOR'.INFORMATIO
LDWG ADDRESS: PERMrr N0,
21111 RAINBOW DR 02030101
NAME: APPLICATION SUB DATE
ROBIN ANDERSON 03/20/2002
ONE: SANITARY NO. CONTROL NO.
t
p e Z ARCHITEC)ENGINEER:
O C BUILDING PERMR MFO
�j BLDO ELECr PLUMB MECH
_I U L-1 LA
Z LICENSED CONTRACTOR'S DECLARATION Job Description
ZyS Inercbya�rm lhalln 3licensed and and Promof Choptee.and mmecense KITCHEN REMODEL. P�
:t wimfecdm]t100)ol Division3o(Ne Businey and Prot2uions Code.andmylicenu
2 is in fu eendc I.a �®K V LDldcsc�nse Coned l0 7be
oG A` CTS DEG ON JUN 2 5 2002
4 1 understand my plans shall he used as public mcmds
,K2
p O Licensed Professional
R� OWNER-BUILDER DECLARATION
1 thereby by aifiiexempt from the Contractor's License Law for the
t? following reuon.(Sectiontht 1I 1.am,Business and Professions Code:Any city or county `S(LJOJt{IJly7
R C which rc res a also 1°conswc6 oner,ins rove,demolish,or rc
qm pe p pair en umnurc
nor to its issuance,also rcquircsthea licam for such
that heiilicensed puromom to action UrsofDivisions of de,Co..."Banots License Low(chapterCor) �!y Ft 1 Valuation
(what[;a d6nij Section therefrom
and the boson 3 0f the lcga r i and Professions Code) r I{3jy?Z DOW
:..\s� ,t
or that tie it 31.5 b zany applicant
ben and the beers for the subjects
the
t.Any l violation '
of not more
than five
ydred ollfor apemdtxubjens the opplicam toacivil pemlty
of not mnik man five hundred aml,ra asoo). 10�PN'RJ�ATI ON Occupancy Type
°I,es Owner of the propcny.w my employees with wages its their sole compensation, _
Will do the'work and the nmcture is not intended or offered for sale'fsea:70ia, -
'Bueineis and Professions Code:The Commamr's License Law does not apply to an 103 - UFER Required Inspections•` '
r owner of property Who builds or improves thereon,and who does such work himself
Or Ihrough his own employees.provided that such improvements are not intended or 104 - REBAR
'.Bared lFmle.IChowevev the building or imPiovement
'compinion,the owner-builder will have the burden of proving that he did not Wild me 105 — ANCHOR BOLTS i " '•
improve("purpose Of sale.). 106 - SEWER & WATER _
._ --- . -_._..... ..
°I,asctcater rojecp(Sea 7.amessinesslydProassion,Coda:)sedconuecromt° 202 - 'UNDERFLOOR PLUMBING
construct the project(Sec.0049,Business end Professions Code:)The improves
th rea i
License mdosenotapplytoen°caner Of property who WildswimprovesthtoII,c 203 — UNDERFLOOR MECHANICA&" '
end wsO covwrn for urn projau.wiN.a cmwmor(a)Ocensed.punuant ser int.
°l am eumpl am sea._... _. ..._ -204 "-'-UNDERFLOOR' FRAME......._... ..._.. . .
Convenors Liccn
Baer sec: .' e'e1.Pcr°r Inter tees°" 205 - UNDERFLOOR 'INSULATION
owns« D'eie 301 - ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION 302 — TUB & OR SHOWER
I hereby affirm under penalty of perjury one of the following declarations-. 303 - ROUGH MECHANICAL
(f, I how nd'will maintain 8 6olifiestc of Cmant to self-insure for Worker's -
Compmntim. as provided for by Section 3700 of the Labor Code, for Ne 304 ROUGH ELECTRICAL
pOdo.me of Ne work for which do,permit is issued.
305 — FRAME
°11i end wi116uimi in Wbrkei%Compertantioe lasurrou ce,ai rachr by Saction 306 - HOLDOWNS
3700 of theLabor Code,fed the performance of the work per
which this permit u
Issued My'Woh/a s C.o�mpenution Insurance can and POGcy a her ares 307 ,- INSULATION
No, •,_�, a. 308 -; SHEETROCK,;;; "
,i cerzrmcAnoNCIFBxEMPn NFROMw0RKE1tS v'3r0'9 `—"BXTERIOI2' LATH
'7 COMPENSATION SUR.ONCE.v..� . _. ,. ._ ._ ._.....
i•...,1 _ ,... , .. _ 31G' ,r ''.INTERIOR--LATH _ . -.. ...-. .... -._..---.._.. ._
semen Beed not be completed if the permu is for one hundred dollen ..
(slop)°r!aso) 311 - SCRATCH COAT
' scciury that in the Performance nn work for whey, a oWl : :.
31.3 '.ROOF'NA-I I
sllaBn lemplaye ypcnon in any amnnc to bimes.bFtta th .•. -. _ - •-• _ ..
workers 501 — FINAL ELECTRICALIENERGY
ComPense!on Laws of Cahfomre Dene -
App''ns` 502--- FINAL PLUMBING ENERGY -
--
NOTICETOAPPLICANnIL after making this CenJnleo(Esent on.you should '-
z t becomesubjuuothe warkeexCompensationprovi:lomofthe U Ca"'you mum 503 - FINAL MECHANICAL ENERGY
op roNbwithdomplywithsaehprovisimsormiapemiitaheRned.nadravoked. 504 .-...FINAL. .BUILDING ENERGh".
' ti MNMULMON LENDING AGENCY ..
a, oflhe q a' it ork(r kfor wh eh this permit
rmit n issued(Sec tsaco3097 CIJ.
nswcbonlend ``agencyfedtheperlbmience 505 — FINAL ELECTRICAL
GGw "
Wt
q enaesaNune C) _ 5.06_.- GAS TEST. --
z
Upshot's Ada aa' : 507 - FINAL PLUMBING..
U, Q I'artily ihatl have reed thio eppliution end stale that Ne aWve information is 508 - FINAL MECHANI CAL
cmmn:t.I agree m comply with all city and et p tty ordinances and stele laws relating 509 - FINAL GRADE
O:: to Wilding constriictiomitrd hereby authorire represenulivis of ddi city mmmr upon
}�'-{� the aWve-mentioned Property fed inspection purPOses.,,, 510 — FINAL PLANNING
L,r 46 NO Since to save,indemnify and keep harmless the Cry of Cupertino-against
FFedw CO) liabilities,judgments,costa end axpenus which may in any way accrue egainat said 514 - FINA PU I C WORKS
City in nsequcnce of N ting of Nil permit. --
s I .0 AND WIL Y'wrrH'ALL'rati -Potrdr' Issued b L
Y Date
'' FiA7ARD0US MATERIALS DISCLOSURE
Det Re-roofs
pplieniw future Wild ig«atpent'nua Or Inndle harndous mannial -.-Type of Roof_..
ay es dcfned by cal.thtie Cuperno M m I Code Center 9 12 d do,Hesllh and Safety
" . . - . .
Code. s333U)? Io �.i s. g - f Ii.. t :
°Yei 2 :f.
All roofs shall be Inspected.prior to any-roofingmatenal beipg.mstalled.
Will the applicant an'foure budding weapon use aqulpment oraeviceswhich If a roof is installed'without first obtaining an ins ection;I'a an remove
tat hared us au °num amu u defined by the Bay Area Air Quality Management,trig P g
e °" all new materials.for inspection. Applicant understands and will comply with .,.
allno"ti-point"source regulationg.
hi,7 reed ine'hezerdo materials requirement,;vohn CTaplor 6.95 Of the
Cill inniie Health&Stacy Code,Sections 25505,25533 and 2553e 1 understand then
if
pe it ild gdoµvolcturc we aunant,that it is my responsibility to notify the
P t the u' men h matra un be hint pdw,to issuance of a Cenificata'of
Signature of Applicant. Date
nes, All roof coverings to be Class"B"or tietter
_
OFFICE._.._.-. -... '
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S0 . 39GdHIVE QNV N3i01IN ZZV �961166L80b 110:60 L00L/BVE0
D O
CITY OF CUPERTINO M 0 Z 3
"TM°F PERMIT APPLICATION FORM
CUPEI�TINO
APN# Date:
3Ga /00.5 3_ao-a a—
Building Addr s:
-?////
Owner's Name: Phone #:
Contract 122 Zkbp License#:
�3 7//7�,
Contact: Phone
� yob 7932-/1 96
Applicant/Contractor: Fax #•
19 ,2 z XJJLYAW ��/� �ya� 79,5--/19
m g PermiYInfo: �
Bld Elect lumb ech
Job escription:
Residential: ppmzo4el Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Ar chitect/Bngineer: Valuation:
ype of Construction: Occupancy GIrou
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to I 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
BCONSTAXBQ Con. Tax for BQ Zone BUILDING',
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V<= 1000A ELECTRICAL
BELEC1001 Elec 600V> IOOOA ELECTRICAL
BELEC200 Elec Svcs 600V <=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housin Mit. Fee I BUILDING
lof3 / � �2 V
OF
CI BUILDI c DIVIISSIIONN� PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
21111 RAINBOW DR 02030101
OWNER'S NAME: APPLICATION SUB DATE
ROBIN ANDERSON 03/20/2002
NONE: SANITARY NO. CONTROL NO.
rM ac ZO ARCHITECT/ENGINEER: BUILDING PERMIT INFO
g mF BLDG ELECT PLUMB MECH
LICENSED COMRACrOR'S DECLARATION
u C
S = I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
iy-
Fu: whns«tionolundofDim>¢m3nrtneBurin�SanaPn,fea.ion,Cars,and mrranae KITCHEN REMODEL.
]yf6 is in Poi sand efjr�t. J`+ 7
,e Littnsc osa /� Lip.a
n Deaf CnmmC10
13 0 _ ARCHITECT'S DEC A ION
°4 I anaeramna my plans nau b<used as pamm records fir/
1 i p O Licensed Professional fit►
Oat I am exempt
from
DECLARATION
oats='w I hereby aRrm thin 1 am exempt from the Contractor License law for the
?ofollowing mason.(Section 7031.5,Business and Professions Code:Any city or county UN 2 6 900 $3 2 0 0 0
which req permit t c m t It improve.demolish,or repair any snucture L
a3$ , pbnots istandece.al.req-wthe 'lcam for such Fermnm flea nigd aurenrenr _-- -- --_ ---- __ _ _
that h-cis.liccaoil punuant to the pentsisions,of the Contractor's License law(Chapter 9 y F(,,Egg �e y�p,� v, r Valuation
(commencing ith5 ti 9wlp fDivision S of the Builncsr and Professions Code) �.'�DyN !'t43jkv-,1nUs(j, iL! t ((9 t,
or that be t5 eaempa therefrom and the basis for the allageb exemptlod Any violation
V
of Section RO 1.5 by any applicant for a permit subjects the applicant to a ovenaltyIn
'rfnm mom man five hundred amara($5W). a p 10 l PN "'PFJMDAT I ON '"'°"' 'I "' Occupancy Type
°I,as owner of the progeny,or my employes with wages m their sole compensation.
-willme atrv:ureThe C not d or License Lad foes not apply
toa n 104 - REBAR Required IDS
twill-dos ens Professions Cotle:The Contractor's License Law does not opplr mon 103 - UFER 9 pections:11''
owner of progeny Who builds or improves thereon,said who does such work himself
or through his awn employes.provided that such improvement ore not intended or -_
_of(dcd(or sale'((;IidwcvcF,sic boildin _... ..__. its sol]-within enc-m . ..__.--..___ _...__.. ;.., _ ..__......._._.
g°rCmPrnvemin re 105 - ANCHOR BOLTS "r "' •c �:' ..,:+"'
'completion,the owner-builder will have the burden of proving that he did not build or t
improve for puryose of aale.). 106 - SEWER & WATER '
owner_. _.. - - tracto - — - _.. — _. ..—
"°hmucthenishcproecny Business adm�actwimasCr en.eacommoorsm 2'02 - UNDERFLOOR PLUMBING 'I::
- = eon:wetane does
(Sec.1toa,owneroaaneerrywhoteme0Thecontracture 203 - UNDERFLOOR MECHANICAL1i
Lianas Law does nm apply m an owner or progeny who builds or improvu thereon,
.
cord-who contracts for auch.projema_with.a emmcmgs).licensed,pursuant.m.the. ._.. ....... UNDERFLOOR UNDERFLOOR--FRAME- ._.._...._ .. ..._,---_--- --.. ..._.
Conbacters License law...,. - "----
- -i ❑1amexempt voider Sec. t" &,PCforthistemxm 205 - UNDERFLOOR II-NSUL`ATION
Ow
npe " '"' " ' Dmc' 301 - ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION 302 - TUB & OR SHOWER
I hereby affirm underpenmtyri,erlofimc Orme fmmwingdenamtitwe: 303 - ROUGH MECHANICAL
C7 1 have Compensation, as
maintain or by
of consent io se Labor roe workers 304 - ROUGH ELECTRICAL
Compcnsaion, as pmvided-Por by Section 3'100 of the Labor Code, for the
_-_ pttrnmtahseoftheworkfor•whichhisFiTmiraiaauea.,.,,• 305 - FRAME
°I have and will mbinimi Workei s Cdinpensaunv msurana.as required by sccdun
306 - HOEDOWNS -
37W of the Labor Codd for the performance'of the work for which this AT N OF EFerris is
issued.My Worker's Compensation lnsumnce coni ani Pmmy
CERTI307 - INSULATION _
e )il •�/t•f i,' PnrerN . lit
f 3`09a•`Y`EXTERIO'RSH]qETOCKLATH .. .. --�
t FIIOXEMPT(
NFROM WORKERS' x
COMPENSATION INSURANCE-'-1- _- _
.}_ ._...- _—. __ --_.__.
310% INl1ERIOR LATH- -
1 flits sanaon need not be cempineJ if the permit is for ne noodled J°Ilon "' •s '
csloo)nr lean.) 311 - SCRATCH COAT :
— -`3-13' -=-ROOF"NAIL ' -
• I miry th c per of th k f -n cit puts t 6 sued 1 .. - = r �;,a.'.t .
c°°ml t nil Laany wsof calrnmu.any
n` s ' m'bccmncsubject o me Workers 501 - FINAL ELECTRICAL' ENERGY
..Applicant ., C' • C
" " " -- - -- 502 -- FINAL--PLUMBING-ENERGY --
NOTICE TOAPPLICANT.If.after making this Cistar s f of Exemption;.ycor mulct
Z bechwithcmplywhN'uchprvoionsortionpmvitshall mdeeeedrevo,youmust 503 - FINAL MECHANICAL ENERGY
00 forthwith comply -504.-. FINAL._BUILDING..ENERGY.
-W o", CONSTRUCf10N LENDING'AGENCY ""
Iti 'by in.ththemomaiuci lending agencyf the peAoem a 505 - FINAL ELECTRICAL
of the work for which thsp - is issued(s 430iG CN.C.) - GAS_ TEST
Lender's Name.t..t. :a r,.., t .„',.. ... .- ... .. -- .. ___.._-_. __. . ._.. _.. ... ... ... . .
DIZ Iand«sAddress - 507 FINAL PLUMBING ,
UO Icenif thmlhave rend thine t dsmm thmthe above information is 508 - FINAL MECHANICAL
tnuE:6
correct 1 ag_e to comply with all cityandcounty ordinances vM state laws relating 509 - FINAL GRADE
O.,U to building conatrvction;and hereby authorize'represimernivei of this city m ca"rupon
. rW thenhove-mentingeapropemyforinsFccionpurpnses.- 510 - FINAL PLANNING
p. I Wc)ogrcc to save,indemnify and keep harmless the City of Cupenlno against
Vi liabilities,ryagmenu,costs and expenua which may in any way accrve against said 514 - F I NA PU I C WORKS
U.^ Cnya - nsequence arih an of leis permit.'
'APP( ANT,UNI[RS
is ANDWILI FLY'WITH'ALC'NO :POINT'°' Issued b Date
ran rc Dto Re-roofs
'( a
HAZARDOUS MATERIALS DISCLOSURE - ''”
'• sen applicant or f t re Widding'osacupantrair,or hahale has rx mmerial. ...Type of Roof_.
ea refired by th C pen M al Cmtl Ch pt 9 12 d aM1 Health d Safety ii a s a
' a s
Code:S o
n 255J21a) 4� .. ,
t\ °I- s 1 �-lt All roofs shalI be inspected prior to any roofing material being installed.-
,I hazardous aisen theapplicant fincow building occupantequipment rde'«s witch If a roof is insialled'without first obtaining an inspection I'agree_to remove
�
t t r contaminants r defined ed b the Bitr A A r Q al ty Management amat all new materials for inspection Applicant understands and will comply with
ova all non-point source regulations '
1 hes dread:Safety Code. mamns 2 requ rement under Chapter 6.95of the
C616fomid Hearth&SufetyCWe.Sections 25505:25517 and 23534.I understand that
B1he Bd'dkie not cumen ave vcnan6.that it is Cny responsibililymnfien the" t6, „
ac p ht the rc u' -mens 'N h must be met prior m issuance of s Ccriffcatebf
a.
Si nature of Applicant Dale
'i
Own nam:gem Dam All roof coverings to be Class "B"or better
OFFICE-.. . .. _. ._. _ .
sat-.'. :...... ..... ._. .. -. _ .. -- - ,. ... .. .,_ ..