01040146 t ,
CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10631 TUGGLE PLACE 01040146
OWNER'S NAME APPLICA'I'1UN SUB DATE
KEITH KOLKER 04/26/2001
PHONE: SANT FARY NO. CONTROL NO.
nstARCH1TECGENGINHEW BUILDING PERMIT INFO
00 BI.DO ELI!CIPLUMB MECH
N7� I=1 l-1 1=1 1=1
NNLICENSI?D CONTRACTOR'S DECLARATION Job Description
y o hnvhy nrfirm dmf I:um we ed under pm,vm.....of Charier 9lcnnm encing
m F el with S.,lum 9IXXBol Dm,ion 3 of dw B.,uw,aand Profe,,usto Cale,and my lteenw
x is inmBforce and effect. DEMO HOUSE
s z a Licence Clms Liv,a
fnx' n tJ [);.,cContractor
W 3 a y
ARCH'IITC
rI DI?C LANA'I'ION
C t=O g 1 undersand toy plans shall be used as public record..
cit't _
a ao Licensed Profcssiotnl
%es OWNER-BIJILDER DECLARATION -
ulI
To1 he"by n0irnt that I i tnpl'I..n the Cumrueni st License Law fin the
ria fallowing renin I.(Section 7031.5.Business and Profesaiay.Cale:Any city or county
5=O which"fire,.permit to rumtomt. ltar improve. re,airmi,,muctime
w
prior to itst alse Tc,mrc,the up,licamfor such{N in to File a.b cJsta¢mcnt
d3=
It.,he is I (para II m p n1 c t lur I' 1aw(Chapter 9 Sq. Ft. Floor Area Valuation
feuramue ng with Sanion Y(HHO of Omeum 30 the Bovines end Profession,Code) $6300
or that he is esempl therefrom unit the oasis for the alleged eaemptinn.Any smImion
of Section 7031.5 by any opplici m for a I comil subject the applicam to.civil penalty
ur nal Inure man fi.hundredduBnry(s5(m), A PN Number Occupancy Type
0 Las owner of the prop,d),or ttty enlaoyees with wage.,as their arm cutnpcnsmion. -375310,166. 00
will do the work,and the structure is not intended or olreced for.vale(Sec.Bw.
Business and rrafea.aon.Code:The Contractor.License Law d«.not apply to an Required Inspections
efproperty Who builds orimprove.thment.and whodeessuch work hirlYelf NO ASSIGNED INSPECTIONS
or
or his own natployces.provided fen...It impreven,ru,are not'ru,ndletl or
offered Int sale.If,bmvever.the building or inipmverni is sold within one year of
impletion,the comm.mtimer will have roe burden of proving that he did not build or
completion,
parmseof sme.1.
D I,as owner o1'the properI,um uscla,orly contmeting with Ilttmal cturnmetms In
m.trua life pmjcm(Sec RIfJ.Business and Profusions Code:)The Cn mic"'I's
Licence law Jas nal ripply to an owner of pmpcny who build,or improves thereon,
and who contracts for.such project,with a anntranor(s) licensed pursuma to the
Contreclorn License law.
D 1 can ese,na under Sec ,13&1'C tar this....... c
owner nate
WORKER'S COMPENSATION DECLARATION l
lttJ
herebymrnttteer Pendry of perjury one of me raauwme declarations:
❑ I have and will t nwie a Cer ificme of Consent b xlf-insure for Worker's
Cuntp.,,uin I, v. pnonled lila by Section 37(H) of the [..her Code, for the {'
plrlarma n,r,n tc work for whltht mice perun i,issued. e
01 have and will maintain Worker s Compensation Insurance,as required by Section
370K1 of the Iamr Cuda for the l rfor m cc of the work lin which this permit is �•+
i—tsl.My W ukur's Camp,T,1;line Iuwmnac ci ic,T d Policy mother art: v/�
Cimer. Policy No.: s�
CF.RTIFICXHON OF EXEMITION MOM WORKERS
COMI'I!NSN'1ON INSURANCE
rl hissection need not be completed if the permit is for one hundred Jnllms
[51p11 nr IcsnJ VVA
I certify unit in the perk rtuarce of the work lir which this Perron is issued,1
.hull cut employ any l ' v t b object be wad.,,, O/ �)
Cimi,ifinion Law-1 California.Lane
Appl cara ^j
NOI Z7 IU APPLICANI If,ether making this Cnf I f Exemption.you'should s!
Iva I n tl W k L I f I I theLabor b C I Y a it I
Q Q Iimhwnh conply.,'It such pnwaumn,the.per itQed be duo,ed,rvuked,.
F ^ CONSTRUCT ION LENDING AGENCY
I hereby'etfiun fh:n there ix a conanmtion lending agency fur Ihc l e forfemi
W '7 al the wok lin which lhl,peon u is i..uM(See 3091,01.C.)
L Q Irender's Name
= 7 Lender's Address
U C) 1 ucn lfy that I have WRd this apPlil:dlun:n d state that the above infnmtation I5
Rs E. comYl.I ogre,ria comply with all cily:md eonnfy ordin^nac and.wale laws relmn,
mmw . )
Q t.7 lobuilding construction.and hereby,awpa
honie reewnmuofla,city o tivenmrupmt
F (y Ihc aMrvemunumed progeny for iopechum pur ww..
Fy IWe)ngre=meavc indemnify and keep harmia.the City of Cupertino against \ ��
r/J Iiahllltiel,juJgtnetns,Inas and capcn.c.whtah m;ry In uny wiry "cow a,muel sad _ b I I
U Z City to lmr.o sen«lathe nmuing nl'this nernot. b
4 6
SOURCE
AND WILL COSTLY WITH ALL NON-POINT Issued by: Dale
SOURCIi HEGUhATIONS.
Signature if nppucalf/Conteldmr alae Re-roofs _
I IALARDOUS SIX]'TRIALS DISCI.OSURI!
Will the applicant or Frannie lmddlae nocupnl score m handle ha ardtms matemil Type of Roof
as defined by the Cu,scmna Municipal Code.Chimer 9.12.and the Health and safety
Cale,Stain i 25532(n)f
D Ye, C1 No All roots shall be inspected prior to any rooting material being; installed.
van me apphcam or mwre lmdding artTupa^l ase egRirmem nr Jc.aces wnien If a roof is installed without first obtaining an inspection, 1 agree to remove
mit hamrdouc air coneurnma is m defined by the Buy Arca Air Quality Management
Di.strict'T all new materials for inspection. Applicant understands and will comply with
oyes ElNu all non-point source regulations.
1 have rend the havardous material%requirements under Chapter 6.95 of the
Callfnrnin Health&Safety Cale.Sections 25585.25531 and 25534.I understand that
'Ee building anew naureenfy h:ot rv=a tenant.th�t It is my fc"omibilit I hey the r
upunl of the r,sirenmm,which mull be incl print to 111-a-111 al a Cindicate of
apear" Signature of Applicant Date
Ownerur aeh sed abet, Date All roof coverings to be Class "B" or better
OFFICE