00070117 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
13UILI)INGAf.W3 =6 TONITA WY GERNER DEANNA ,J AND •H`§�NOJ ET0007011.7
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oWNrR'sN.�v�:RNER DEANNA J AND KARL ET nPPLlrrcnc[ �14/2000
'HONE:: t SANI1n10 NO, Coeo'ROL NO,
IIIUII.DING VERhIII'INFO
�reOO ARCIII'I'ECT/ENGINIiHN: ❑hUG '.IifT i4ll 1,11:01Co _
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I.I lflhn IDCON'rltnC',,do, DECI.AoATION Job Description
1 hereby soon mat 1 all:neoism uoden proI P to Liles Code 9 mnmmenense
Fytal wahsrora.lin ofT)idsn,n3s.nhnRnsiocssamn'rorossitufscoel.andnfyfiansc REMODEL
Y$ i>in lull hrrcc and 01,11. ,
z i a Liccnx Class Lic.x
K 3 O Doc Cameroon -
u.ri, ARCIII'IECI"S DECLARATION
e g 1,nWemmnJ my phfuasnwl w nsed as p,mnn 1111and,
�r
are6+S p C Littmsed Ihofcssional
OWNER-BUILDER DECIARAnoN
1 hereby,(Sect that 1 am t•M9np1 from,he Cnoors Cos Licence Law for the _
I.'a¢ f hnhire mason.(Section 90.11 5•Ifunineu and otirdoo fi lh.vas Any city Lir county
SSC whomnsilmapermit to remm,thetDike Impmvo. permah.nr repairedwheelers
C 'hit he islcense caaLnn:d purnomit to the
lhovisioso rarities pennil Liiense Law(Chapter
.a5� 'hatheithSetion7tnepm.Doisian3ortf the hemnnc%santn,eLaw(Chaplden Sy. Ft. PloorArea ✓ V:yJ�t;rpc�
(commencing he is a sump Section om n or of basis 3 or R gedesn dna rrnrrcnya i cute) / S CId1410
or that be Is exempt any almm and ar,Haas for he steges namnpoon.any oiolarmf
orforroa,thaniv flayarphamlrs($50nn)In.a,ial meapplle:nn fnurisu fwnw,y .
ornonm,re man hoe hamo-m dolor,(55(aq, APN Number ,C> Occupancy Type
❑Las otherofk,aparafterty.wend
my cmployaawish wogecetheirnotele(Se.70cr4.
35915050. 00
will n the wink,sad the odle:The is no,intended J ore Law for nal,'(Sec.inlot Required
Bus 1[.,anuJ�ryWiohsive: repiover llnrnLeannelawJncanmapplyInul 101 — FOUNDATION
or
ill it,of t Who loyeL ori us thereon,im r who d.ws re wink n ed it
or through bids awn cmpinyeen. budded that such Improvcmcnls me nil intended it
atoned for sale.H,nowanr.the Hooding e f imparofun n sold avenin one year or 1.02 — PIERS
`ompl hu tic owncnbuimm win novelle butJen of prodns that n1[Dia sur Woad or
mpmoe rat purnoaconae.). 103 — UFER
131.a.s ownr,ofinepi...ey. an laeln,ivclr antmerng with L-nosl ronnu lo,m 1.04 — REBAR
Li,nuns,the project(Sec.7094.Bu.dnc,s aced rmfca%iml..Cuds:)The Cooravors
cense law apes not apply to an nwnor of penitent who Wilds or impmres mconar 1.05 — ANCHOR BOLTS
and who contracts for such pmjmrs with a comruemgs)licensed pursuant to he 106 — SEWER & WATER
Conlranor's License Law.
El alt,string,order See. .It&it Cin his feta"n 202 — UNDERFLOOR PLUMBING
" WORKERS COMPENSAl7ONDECLARATRIN 203 — UNDERFLOOR MECHANICAL
Ihereby anion under penalty al perjury one of the following declarations: 204 — UNDERFLOOR FRAME
I have and will mantunt a Lenificafe of Conwin m selt.innum for Worker, 205 — UNDERFLOOR INSULATION
Cotniscmatlon, as prodded for by Section 3700 of he Labor Code. for the 301 — ROUGH PLUMBING
,diumance of the work for which his permit is imued,
❑1baseandwwm.,iotainworker,C..mpen<ali In.umnce.its rc4niredbySeaton 302 — TUB B• OR SHOWER
C1"of the Labor cods,lot the herr nuance or the work It,,111[111 rd,pemfif is 303 — ROUGH MECHANICAL
issucn.My workers cornpcn.aron assurance canhr dna policy nmuner are:
cammn roheyNn.: 304 — ROUGH ELECTRICAL
CERT incx'r1oN OF EXEMPTION FROM WORKERS' 305G — FRAME
COMPENSATION IN.SURANCli
306 — HOEDOWNS
rlain.croon nerd not lin eo.nplmm it nfc permit i,liar one nunecee dolor, ' 307 — INSULATION
151(x0 nr los
1 certify mat in the pecoumfam,c of work no which this penin,is issued.I 308 — SHEETROCK
shad not employ any parson in my man ter so as in nccona,subject it he Workers
comforioomLaos ACai(hrnia.One 309 — EXTERIOR LATH
Appuau,
Nm'ICI';TO APFLICANI':If.short making his Cenifcmc or Eactnption.you should 310 — INTERIOR LATH
bosom subject to the Worker',Compensation provisions of the Labor CNB you must
p O Iarfloerncm,lily with lath ptovision.ormil pemn'hill cdecmalrevoked. 311 — SCRATCH COAT
y
CONS TLC NON LENDING AGENCY ' 313 — ROOF NAIL,
I Leahy anion that more is a concwction leading agency for he performance 501 — FINAL ELECTRICAL ENERGY
of he work for which,his Narasin is is.mcd(Sec.30'17.Civ.C.)
a $ Leaders Name ' 502 — FINAL PLUMBING ENERGY
Lender',AJdrea,
0 I cenify that 1 have read this appncahon and state that the thus innrloauon is 503 — FINAL MECHANICAL ENERGY
Fcorrect.1 agree m comply win all city anti county on inane and state laws retailing 504 — FINAL BUILDING ENERGY
p [, ,o Molding construction.and hereby authorial Kpmmntatives of this city In enter upon
the thoor.menron«1 solvent file inspection parposec 505 — FINAL ELE R I CAL
(We agreem,asr,meentnif,and keep mm..less he Ci,ol'Cupenino agama
to limine,,judgment,.costs and cspen,cs whim any in any way accrue against said 506 — GAS TEST
City in consequence ol the Sterling of this retain.
APPLICANT .LAT`_UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: 507 — FINAL P U G Dale/AsO
URCE REGULATIONS. Y'
.t•nul 'a of Ael"it"Coit a fine Re-rOOIS
w
HnzARDouSMATERIAI.SD1SCLosuRla 509 — FINAL GR DE
Will me applicant or future Wildingaccupam none or handle ha..wonsnm.cdal Type of Roof
as defined by the Cupertino Municipal Code.Chapter 9.lo_,and the Health and Safety 510 — FINAL P
IF
Code,Salerno 3532(x)'
❑Yes El No All roofs shaif%t4nstit�cEcTNM-t(PJofolringWOPtHS being installed.
W 11 the off]cunt it Emma building nrcuplml me eyuipmwa Lit devices which 11'a roof IS installed without first obtaining an Inspection, I agree to remove
nil hvardous air conuminams as defined by the Bay Area Air Vual i,y,Management
ioricV13is �N all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
I bass read the humrJuun mumrials requimnavus under Chnpmr 69,5 nr the
California Health R Safety Cale,Sections 25505.25533 and 25534.I uNcrsland that
if he building does nn,currently have a onant.that it i,my respnnsibilay m notify he
upon,of the requirements which must be met procto issuance of a Cenificum of
`eeupaney.
Signature of Applicant Date
Owner nr aamnrisca agent Date All roof coverings to be Class "B" or better