00120023 CIRUIoPNUPFRTNNO T CONTRACTOR INFORMATION:
_ C �ti
BUILDING ADDRESS PERMIT NO.
OWNr.R'S NAME:: s _ _ _ AND BARBARA
AI'PLICA'I'ION SI �nA'I' " `
D�
1 PHONE: SANITARY NO. CONTRUI.NO,
K>. ARCHI I'PC'roHNGINEER: BUILDING PERM[I'INFO
0 0 NLDG F1 PC'I/ 1'LUMIi MliCll/
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Baa
�N= LICBNSED CDhnxd under
DECLARATION ADD '2ND UI�11iT /Wilit RYEL EXISTING
o = I hertion 7 aRrm ivi 1 len tuned under provision.of as apter Code.and(commencing u01 with Section elce and e f llivi.ion 3 of the Business and l'mfevnium Goa and my licca.
c rc ¢ Llcmin ra Class end coat. Lia.N
Unte C ancmt PINA
3 a¢ AR0I I HC'I'S DLC.LARAI'ION �
Cf5 O J 1 undesired ley plats shall he tied as puhl is rc"'n],
ne
JUL 16 200s
tua ce
i p O Licensed Professional /
n OWNER-BUILDER DECLARATION
W I hereby a1Enn that 1 can exempt from the Contracuds License Law for the
IZ Q following rc: (Section 7031.5,Business coal l f Castle:Any city or county
$m wM1 h 4. I i t construct. It p demolish. p y s uaurc BUS I q
u
w3pap priort tsv I: I IIapplicantl suhp. a 11 b J.emmard � •
a
that he is licensed nat ce India go...........I the Concharlor,Lecuse In.IGamcr1) Sy. Ft. Floor Area Val �h> `
B.maraming wiBl$suns 7akq of Divinin 13 of he badness lad l'mlcsdons Code)
,or thm he is excmpl thcml'rom and the bmis for the til legcd exemptionAt,,violation
of Section 7031.5 by any applicant for v pant subjects the applicant to a civil Penally
\fuel marc than five hundred douost($510), APN• u r Occupancy Type
11 .as owner of me pmpcny.or roti employees wile wase,as mdr rule emttr emscatinn,
will Jo the work,and the soudurc is not intended or offered for sale(Sec 7011.
Business and Prnfee.ions Cade:The Connaaor's License Li tan not apply to nn 'ctlons
owner of pmpany who baud.or i:npro.I,thercnn,and who does.such work himeh' 1.02 — PIER
'I E R
oruogl his awl r:nployers.pmvldml that Inch improv cros a mut Imntded it
Harcd I,),sale,u,however,ma l aaAmg m hnpmvemc n i sold within are ,.car 103 — UFE R
nnpleime,the nwner-hai1d,,will Iowa the hunlen of prom l:tl ha did not build nr
improve forpampoaof.ula.). 104 —
REBAR
01.as owner of the prepany,am exclusively contracting with licensed contractions In 105 — ANCHOR BOLTS
Instruct the pmja11
t(Sec 90 .Business and I'mfn.inm Coda:)TM1c CoMosa ors
License l.Iw does len apply In an mortar of property who builJe or itopowas thereon. 106 — SEWER B WATER
:Ind who connects for such project.with a anmmcrrts)licensee smut
par, to the 202 — UNDERFLOOR PLUMBING
Conlrxcmr4 Llama Law.
ala:o e. ll nd"Sa. R&PCImdo,re:""" 203 — I_INDERFI_OOR MECHANICAL
2104 — UNDERFLOOR FRAME
flRKl: 'S C(IMPL'NSAr ON DL'CLARA ION
Iheren remmander h f fthefollowin declaration.: 205 = I-INDERFI_OOR INSULATION
hereby Penalty perjury ansa g
❑ I base nice will o e:ma:n a Cartircate or Consent to sell-i...ra ror worker. 301 ROUGH PLUMBING
Cmttpco,atior, as pro,ilad for by section 3700 of the L:Ihm Code• far he 302 — TUB & OR SHOWER
pedocrame of the wovk for which On,Permit Ix Ienned.
01base not will lnninlain Wink,,',Cnn:pcqm ensutinn lmmi istuirad by Sermon 333 — ROUGH MECHANICAL
'
3700 of the Ldsor tilde.for the pefrorocmce nl he wrk for which this permit is 304 — ROUGH ELECTRICAL
erred.My Wader,,Compensation In.urrame cosier and Policy mender arc:
305 — FRAME
Cartier. 1'nl'Icy Na.:
CIiR I'IIIG\TION OF Ii%EMI'I'ION FROM W(IRKIiH$' 306 — {"101_DOWPIS
COMPENSATION INSURANCE
3107 — INSULATION
nIn,.aam,mad not be amwplman it „ar:nh is ror one lttmlrcd emwrs
31218 — SHEETROCK
aI w0 m lass)
1 certify that in the perl,nnence o1 the work for which this permit isissued.I 3109 — EXTERIOR LATH
shall not employ any person in any manner so as to Favorite subject m the Wodem 310 — I MTF_R I 0 R LATH
Compensation Laws of Caufomin Elate
Applicant
NOTI)N
ICE IPLICANT:If,after making this CeriEcam of Exmnption,you should 311 — SCRATCH COAT
become subjectn the Workers Cnlnpenuation provi%mrn or me wMrz Code,yon must 313 — ROOF NATE_
Q 0 rorthwilh comply with such pnwishon.or leis permit shall he devoted revoked.,
z v CONS'1RUM ION LENDING AGE NCY 501 — FINAL ELECTRICAL ENERGY
aIhereby ammtato(more,isacombustion lending ogcayfmthe pedbmanee X02 — FINAL PLUhIBING ENERGY
lithe work for which this permit is Issued(See 300.Civ.C.)
oma, o La^ds,,Namne 503 — FINAL MECHANICAL ENERGY
5 7 IsnJer's Addre..
V O 1comity that Ihave read this applicmionand s(amthartheabnveinformation i< 504 — FINAL BUILDING ENERGY
w F c t Ia ply to all city county d laws relating 505 — FINAL ELECTRICAL
O C) t h 'I(I b' ( I Ih icy II p fi III 6,to moan Phh
A.
.h n d p e Ir f p 506 — GAS TEST 41z_�
y es.pd,reem.lost'o cnnfyand keep which
in he an,City()I Cupertino ap.tma
N Liabilities.judgn¢nte,crnu dna cxpto 1h which nmY in nay war same against said 507 — FINAL PLUMBING
V 7 City in consequence of the gmnlinbnithspenni(. sal
APPLIC UNOBRSTAN A'I WILL V) PLY WITH ALL.NON-POINT Issued by: 508 — FINAL MECHANICADatc
SOU F f 1�LA'1'ION. / - O� _—
SignatmcofALlfle,IlicandiCuntmctor T��/ Re-roofs
HAZARDOUS MAIIiRIAI.S DISCLOSUHII 51.0 — FINAL PLANNING
Width,a,b,,moraareNnld'o'.11NIPIon wnm or ha iia mmaeom tmtcrial Type of Roof.
as Jdincd by the Cupcnlnn Nylnmip:d Gia marvel 9.I2,ana the tic:Jar and Saticoy .514 — FINAL PUBLIC WORKS
Code,0Y"2s532(arr N\
No All roofs shall b60;VeLiedRifI3FtoRhlYMELflQ dWelfUl.being installed.
Nd me appraaatmfuture a budding by the
Bay Area
AirQmor Nfice.wnmh If a roof is instal1R213+ithotlQfifyFobtDAD'6kgFgN6ispection, 1 agree to remove
DiverzarJou.air contaminants as Achncd by the Huy Amo air Vunl'ny hfanagcmem
uisdeto ve. �No all new materialb&¢inspegjyp}FAp�llc.IPp:,y-g11�[:fggi and will comply with
all non-point source regulations.
I have mad me Ia,accous Iw:ncoal..spun n:n under Clea,scr 1.95 of the
California Ilc:tilh k Safety Cuda Sation.255(I5.2553?and 25534.I undeamnd that
it the lmilJing Ares nal cunantiy havenmen' 6lhat it is ror resPo ibilityto mail the
aapanl nl t re4uircmcns I ( to i"uancc of a CaniEcate of
yyy�r hhyytt yVV 1h,�yr�r nm
«aulw
_Z51
_— �„[ / Signature of Applicant Date
wl - ' /1St/� / All roof coverings to be Class "F3"or better
owner or nnnnhd,ad:Igaol
OFFICE