02060072 CITY
nrnONO
BUILDING SSINPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRUSS: PERMIT NO.
22423 RIVERSIDE DR 02060072
OWNER'S NAME: APPLICATION SOB DATE
•TOY THOMAS T AND MAY F TRUSTEE 06/13/2002
PHONE: SANITARY NO. CONTROL NO.
n ac ZO ARCHITECT/ENGINEER: BUILDING PERMIT BJFO
m- BLDG ELECT PLUMB MECH
y¢a
LICENSED CONTRACTOR'S DECLARATION
1 hereby «nn mw 1 am hcthsce under fcha v add
mmendn Job Description
y a provisions o per g
,rt is infllforceandefect. on3oftheBusinessandRofcsxionsCode.andmylicenx ADD 135 SQ. FT. /SHOWER
at Lnum lltmceandmrtect. ����
.,, 6 License Class Lic.a �'p�a
-O c U Dae Contractor e
1 3 u.IGn ARCHITECT'S DECLARATION
J 1 understand:ny plans shall he used ax public records
;'1r AUG 2 8 2002
E o o Licensed Pmfictio nal
OWNER-BUILDER DECLARATION
se--'u' 1 hereby of arm that 1 am esempt from the Conuacter's License Law for the
L?Q following mason.(S«tion 7031.5.Business and Promotions Coda Any city or countyes BUILDINGfi 13165
es x o which equ p rm: canister, Iter Dro demolish, p any awcmrt
Re Pro to its Issuance.elsrequiresthel such permit fl signed statement
Bull he a licensedp num moi pro .ion.of me Contacted',License La (Chagcr9 x'•s p,�t a Valuation
(cam a with Scct7000) fDivii Jfib Bines dPh ons Cute) rat-\ ki3.�tlV3, -.-U U'„�ss�,ta 7I 11 Vit'
or that he is exempt from and em basis for alleged ekimp6hn.Any violation
of Section 7031:5 by any applicant for a per m acts the ap,deam to a civil penalty
•ofnot mom than five hundred dollars($50(h 101APN�ATION Occupancy Type
❑I,as owner of the property,or my employees with wages as their sok compcnmtion.
will do the work,and the structure is not intended or offered for sale(See 7614."
'Business and Prnfe..run,Code:no Cammcutr's License Low does not apply on an 103 - UFER Required Inspections
owner of property Who builds or improve,thereon,and who don such work himself
of through his own employees.provided that such improvements mons arc not intended ar or 104 - REBAR
completion:ale.If,collud r;the building of i:hpfovemem n sold within one build at ---- -'""'_.. .. .. .__._. _.
completion,the owner-milder will have the harden of proving that he did not build or 105 - ANCHOR BOLTS
improve for propose of sale.). 106 - SEWER & WATER
_ - : ❑1,asrow neroithe proatry,a�,&cldai.elycontracting wiinucensedcontr;em;sto 202-_._—UNDERFLOOR PLUMBING
construct the project rice.7014,Business and Profession,Cased The Contractor's203 - UNDERFLOOR MECHANICAL'
License Law does not apply loan owner of property who builds or improre
ves theon,
_:. ._and who contracts for_such projects wim.a contractors)licensed porxnam.m.me .-- -- 2'04---- -UNDERFLOOR- FRAME- ---
.
_ dC tnm
mr'a law.
amn ptnne<tsjjc. BBPCfronds clamor 205 - UNDERFLOOR- INSULATION
_ - - owner J: Dae'd/1S/av 301 - ROUGH PLUMBING
WORKER'SC MPENSATION DECLARATION 302 - TUB & OR SHOWER
I hereby affirm under Penalty of perjury one oche following declamnom: 303 - ROUGH MECHANICAL
' ❑ 1 hese and will mammk a C<nif,me,of Consent m.elf-prone for Worker', 3 04 - ROUGH ELECTRICAL
m
Compensation, asprovidedfor by-Seon 3700 of the Label Cade, for the
_ performance of the work for which this permit is issued.
305 - FRAME
0I have and will mai mom worker's Compensation lnsuran o.-as required by section 3 06 - HOLDOWNS
3700 of thm Labor Code,for the performance of the work for which this Permit is 307 - INSULATION
issu d.My W karts Compensid on Insum aper and Poly number an
7 1 . 1` Pnr1 308;4- :SHEETROCK
Cartier CERTIFTCAROWOFPXEMPTION FROM.WORKERS' t ' 11 1_t ` '
coMNelvsA'r1oNNSURANCE'I '- ' 309 $XTERIOR `LATH^
. _ - 3T0-='-INTERIOR--LATH
'film xenon need not xpeted f the Permit is for one hundred dollar, 3111'_ SCRATCH COAT
ISIOU)ar less.)
3.1.3 ....'ROOF--NAIL °
.-['it
c rofy th t in the perlorma ce f th k f r wM1ich th' pe-d is tsstea I �.z:n.
-
Fh:dlItte pIyan p ypactere M1jeumtheworkers' 501 - FINAL ELECTRICAL ENERGY
edmfilfipenat.Pn Ldw rcaht'fir Datli �`' _ - 502 FINAL -PLUMBING ENERGY-
"A cand
""CETOAPPLICANT:IL after makingI I,Ccnifca¢atExemption.youshould 503 - FINAL MECHANICAL ENERGY
become subject to the Worker's Cnmpensaion provisions of the Luton Coda you most p � rorthwith momPly with mo,previsions or his pmmit shall be deemed revoked. 5.04. .= . FINAL BUILDING ENERGY_ ._
CONSTRUCTION LENDING AGENCY " 505 - FINAL ELECTRICAL
I hr iy affirm that them is a comwamn tending agency for me peaortrance
m -
w ':oder:naaRxx '.•,. ._ ..._-.•.. 3lrozci..c.)- 506 GAS TEST _
sof the work for which this Permit is issued see.,, __ - _ ____ _- --- --
a'' 507 - FINAL PLUMBING
UO 1,ertif,unt0hatereardihis.application and state that the abuse information is 508 - FINAL MECHANICAL ,
correc'L I agree ro comply with all city and county ordinances and,late law,r<Iaing 509 - FINAL GRADE
Q C.7 on Wilding construction,and herby authorize representatives of this city to enter upon
theabove.mentioned o,ra,for mspccatr ormses. 510 - FINAL PLANNING
(We)ogre m siva indemnify and keep himd<ss the coy of Cupertino against -
.y liabilities,juegmcn¢,costs and expenses which may m any way acerae against,iia 514 FINAL PUB C WORK �s
City in consequence ofthe'gianeng of this permit.' / �-0
'APPLI NTUNDERSTAN S' ILL COMPLY WITH'ALLNON-POINT ' ISSued b Date (/
SOREGULATIONS./ y
amre c(Applic HA7Aracpr Dam Re-roofs
MATERIALS socam DISCLOSURE
_' ...• WIII t d apphcaht pt fmup huildmg«cuvant ami or M1endk hanrddus material .. Type Of Roof -
es def rd lay the CUre Municipal Cod< Chapter 9.12.and the H ahh and Safety - -
Code aSection 255320als
All-roofs shall.be.Inspected pnor,to.any-roofing,matenal being installed.
WJl tncapplicant or future building p t e eqa p t de ias,.hicn If a roof is installed without first obtaining an inspection, I agree to remove
tun hazardous mr contaminants as defined by theBay Area A Quality Management
1),nocn ' all new materials for inspection. Applicant understands and will comply with
">; urn �o- . al]tion-point'source regulations. ,
�.s 1 M1me read the hazardous materials requimmcros under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that
ifthe Wilding does nmemoselly base alactam,tbar it ism,responsibility tonality the "--' - - - - -
occupantthe regditements 'With must hamet priorn,k anc a of,a Cer 5cae of
° Signature of Applicant Date
ow' "urt.itage��. � Date All roof coverings to be Class"B" or better .
z
...OFFICE - -