02040051 CITYBUILDING DIIVL1ISSIONNOPERMIT CONTRACTOR INFORMATION: '
BUILDING ADDRESS: PERMIT NO.
10478 TANTAU AVE. 02040051
OWNER'S NAME: APPLICATION SUB DATE
CATHY BERGTHOLD 04/11/2002
v'HONE: SANITARY NO. CONTROL NO.
d
pOi O O ARCHITECTIENGINEER: BUILDING PERMIT INFO
t0u BLDG ELECT PLUMB MECH
th< II r L.I I I
LIC'Ory? ECLARATION
1 hereby as nElha EDtCOcNTRtl CONTRACTOR'S
provisions of Chep er 9(commencing Job Description
d_E with sectian1000) fDivision3of the Busines dPmfessia sCode.and mylicense ADD 385 SQ. FT.
:Y i i full farce a ffeq
a Licensy Cl _ Lia too
I 3 aa..n Dag/ S man
=O ,J A HITECT's DECL ATI N -5' "'
ej I understand my plans shall be used as public records
114 po O Licensed Professional An
OWNER-BUILDER DECLARATION
at—m 1 hereby.(lien on I ora exempt from the Cations Co License law for the -
?< following aazon.(Section 7031.5.Business and Professions Code:Any city or county 400
Q Q
f rrc O
which q re e pe t t .tract.id p d oliidu or repair any someone
i _.pr rt a mance hlsorequ r<s Ne appl'cantf r.uch permit to flea geed naamem C� �G - -- -- - -- -- — - - -
- that he Alcensedp rt A.I'athpProl4sio ofth Cot mrsLicenseLew(Chhpter9 f .3 Se r, F�rvsC;gLCafa}u 1"iI,4 Valuation
'ba rte n&ai[h sec[wn]000)of Divi t J of the Business and Professions Code? Ts,J- 9(J "T'
or that he H clamp[thercGom'obd Ne bas s for the alleged el(mmpbbil Any nolauon
-of Section]031:5 by arty applic.m for.permit subjcns the applicnm m a civil penulty-
Iofant amthin.Five hundred dollars(s5o0). 101A'Nr'UUNSATION '- ' Occupancy Type
111,as owner of the property,or my employees with wages as their sole compensation,
will the wore:arta the ode:Thure,e
C not Contractor
&intended of a Law for arae apply ansa, 10 3 - UFER Required Inspections:(
'Business and Professions builds
Th Cantor t License o does m apply m an
owner f property Who l 'les or'mided t thereon and d h workhimself
onhr ash his ow _employees.provided that suchimprovements._ art not spanned o ._ .,_ 1 Q 4 .,—. REBAR,
--offered f s 1' 1(howevcr,Clic bald n8 P i i - Id limn one Y of- ..__. ._._ _.. _ _ .. _..___._ _ ._.. ....._ ....
completion,the owner-builder 105 - ANCHOR BOLTS
derwll have the human of proving that he did not bold or
improve far pmpasearsale.). 106 - SEWER & WATER __
--D 1. s p o f the p pony exclusively contracting co ... .. _ - .._ .. -__... ..
with licensed contractors to -- -- -
` - com uct the p ojcen(s 'lou Business and Professions Candi The Contractor's 2 0 2 - UNDERFLOOR PLUMBING
License Low does not apply to an owner of prapeny who b ms or improves thereon, 203 - UNDERFLOOR MECHANI CAL_u-`'
and who
License Law. contmcmni)licensed pursuant to the ___. .._ ... _ _ . . ..: ..... ......_.__._ ....... .__...
❑lemaes Licenseo such pale ta.w na 204 UNDERFLOOR-.an w o contracts. _ _
; c isc; -` ',9&P,Crorthismaxon 205 - UNDERFLOOR INSULATION
Owknar Data301 - ROUGH PLUMBING
WORKERS COMPENSATION DECLARATION
1. 11. 1302 - TUB & OR SHOWER
,I hereby affirm under prnahy of Ismmrr he of the fallowing declinations: 303 - ROUGH MECHANICAL
❑ Ihave mid will'rwidein'a by-Section 37M
Consent the
reode Worker's 304 - ROUGH ELECTRICAL
Compensation, es.provided for by-Section 3100 of-the Labor Code, for Ne -
- performance of the work for which this permit is Ismed. 305 — FRAME
111 have end will maintain Worker's Compensation Insurance,as required by Section 306 - HOEDOWNS
37M of the Labor Code,for the perfntmance of the work far which this permit is
lse eo My Worker's Compensation Insurance carrier and Poly number arc 307 - INSULATION
Comer rCERTIFICATION OF EXEMPTION FQ 308.; IyHEEy ROCK '.vr v tl ll
MwoRRs P 309 EXTERIOR 'LATH '
, COMPENSATION INSURANCE - —_ ._
-31D:,{'. INTERIOR LATH _.......
fTh s Seaton nerd'not M completes if 0e permit is for one hundred dollars r `
fsl0o7o Ica.) „ 311 - SCRATCH COAT
501 - FINAL ELECTRICAL ......
lcentryiha(i m prfo'ace ftn kr;whentm permtisis a1 - - 313 ROOF- NAIL, - - -
sAall net employ an pe y.�J1 sg�o�y,ora at to the Workers
Compensaton w f e f nDyT'
�AfpIant - - — ..502._- FINAL PLUMBING ENERGY-
:NDTICE TO P LICANT a lie,main h ert Beate fE tion.you should
Z c mesubj&ttoth CompensI u pmvs b iddim aborCoe you must 503 - FINAL MECHANICAL ENERGY
yrn p mnanenb deem. a 504 - -FINAL BUILDING..ENERGY---- -
CONSTRUCTION
0 forth th mnply with s provseion k
•I'"' CONSTRUCTI'ON LENDING AGENCY SOS — FINAL ELECTRICAL '
1 hereby of rm that there is a consimai n ding age cy for the pert it - .
of[hc brk for wh ch tin pe t I_md(Sec 3091 Civ.C) 5 0.6,
W'q Limalm Name " GAS._TEST _
y LnaeraAaarea 507 - FINAL PLUMBING
U O 1 c nay th.t 1 he d this application and state thanh bo 'nformation is 508 - FINAL MECHANICAL
Izt-[y correct I agree .comply with all city and county ordinances and state laws relating 509 - FINAL GRADE
Q t, t.Iamdingconsnuctlon;and herebyeuthorii mpresematives of this city m enter upon
w he above-mepdppedFor t forinspectionpurposes.,. . 510 - FINAL PLANNING
Qa (We)at to save;indemnify and keep hatmlessthe City of Cupertino'against
N liabilities,' dgromms,coas,ead expenses which may in any why accrue gain,,said 514 - FINAL P C WORKS
U'Z City inc u vane of a tenting df tht nen.' "
APPLI NT NO SAND V i I COMPLY WITHAL1�y!�N f
s u E J' N ns i J?v Issued by: Dale
sign o APPlia aV a raetoe " . ate Re-roofs
WII RDOUS ERIALS DISCLOSURE ',
Cdde Sthe eppll o futureb ding oc upant Wore br he dl hazemous meteeial - Type of Roof.
r ._.. ._ ... ..
action - Safety _
�, ,, f be ms acted nor .,.. .3
e madby,i noMunicipalhepar 9 12 and t t
Will applicator,or f i rc building by.,.,.attay a ua(t dManas which If a roof is installedis for ms action. Applicant understands an Ing installed .
Management
a 1 to an z ofin material be _-.
[ All roofs sh_I o
yyu° 'Without first obtaining an inspection I'agree'to,r(p o ve
m t Natrona, Ir caaetmnanb as eefinee b the B Area Ali mem
Dat to all new materia p p d will coo I with
1-IS✓ A ` all'non-poor[source regulaftons,,
a t.
1 have'read the hazardous materials aqutamenu'under'Chapter 6.95 of the
C.lifomia Health&Safety Code.Sections 25505:25533 end 25534..1 understand that
Occup _. ._ .... _. .._.... ... ..
IN budging dams eurrenayneveaten..I,that it is my responsibility to notify the
q mus perprior to bman2P of a Cenifiw[e_of
re uiremenis which
Signature of Applicant Date
U ofmahmom a at gate All roof coverings to be Class "B"or better
6' . . I;a.. .. ., . ... OFFICE
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