01040150 CI DIVISION
BUILDING PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10631 TUGGLE PL 01040150
OWNER'S NAME: APPLICATION SUB DATE
KEITH KOLKER 04/26/2001
PHONE: SANITARY NO. CONTROL NO.
01,
NZrSobfi..7M).fD1ckmm
T'/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
IJ I� L_J ULICENSED CONTRACTOR'S DECLARATION Job Description
eby affirm mat I am licensed under provisions or Chapter 9(commencing
v,I- 7M).fDivision Sof the Bud ...and Profssions Codeand my license NEW HOUSE,
ce and effect.ekoaa Lica 618 SQ FT. LIVING SPACE,
ec3 u. SDECLA � ..: MARAGE.
-w ARCHITECTS DECLARATION
I understand my plans shut]W used an public records
wapce JUN 2 4 2002
Licensed Professional
c a o OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from she Contmmor's License law for the
[_z following raison.(Section 703 1.5.Business and Professions Cale:Any city or county
S.S which requires a permit to construct,aler,improve.demolish,or repair any stmctoo, BUILDING u~&
put t c -1. 4 J plh.' tt hoc 'n M -g d'tt IJ
em.
tIhm hill I licensed vit to tlK t f Ilre Ciontur,on,Levi...la (Llalirt9 5 Ft. Floor Areanation
(en m mmng with section 7W))of o 3 of the Business d Profess ons Cale] _ 1 y', - .,�i(_"• � $3750H
or that he is caempe mercrtom and the basis for the alleged exemption.Any violation I
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty t�1}rnts�p
f not from,mh
fuan fire card dollar,(s5txn 3 7 S�P4� tO .Vb �.' Occupancy Type
V<i,as owner further propony,or my employees with wages as their sale compensation,
wlfl do the work,and the swcwrc is not intended or offeror for sale(Sec:7W4, -- --
'Business and Professions Code:Tho Contractor's License Law does not apply to an 101 - FOUNDAT I[OWired Inspections 17' " ,.
orrv ?fur property Who boilers of improves memo a,and who due,such work himself _
through his own employees,provided that such improvements are not intended or .. 102 _ PIERS .
'offered for role.If,however,the building nr... case rear is sold within fume year of 103 - UFER
completion,the owner-builder will have the t unden of proving mat he did for build or
improve for pmrpfu<e nr.ale.l. 104 - REBAR
OLascomer of the p Ser..7.a adinessred!Pmctingwim assumedeonwctms to 105 — ANCHOR BOLTS •+ '
- Lensed t the does
f Iappl Ito on promeeas pr arty who cede:)The it traemr: 10 6 — SEWER & WATER
License Law does not apply to an owner of property who builds ar improves Merton,
and.who contracts for such projects with a commets)licensed pursuant to the _. .. .. .. .. _ _ ...
eerarto,sLicense]aw; mr202 - UNDERFLOOR 'PLUMBING
m
} ❑lam ex tum ,BkPCfor this reason 203 — UNDERFLOOR'11MECHANICAL
Own,r '°i�L�j/0� ' 204 - UNDERFLOOR FRAME
WOI ENSATION DE LAR 10• 205 - UNDERFLOOR INSULATION
I hereby affirm tinder penalty of perjury one of the following declaration.: 3 01 - ROUGH PLUMBING
: ❑ 1 hale rund 'WH inaimnio'e Cenilicuie of Consist w sril.m,um for Worker's 302 — TUB & OR SHOWER
C..be. or..ion, as provided for by Section 37W of the labCode, for the
_ = prmnnan«arm wnrkrnrwhgnmi.pentaii.i,.aed. 303 — ROUGH MECHANICAL
-' ❑I h:rve and will maintain Worker's Compensation hrkamnce,as required by Section 304 - ROUGH ELECTRICAL
37W or the labor Code.for the performance of the work for whim dri.'permit is 305 - FRAME
is.wal.My Woke/s Compsmainn Insurance carrier and Polity number art:
306 - HOLDOWNS '
Carrier i ." � :.:I"• Policy No.: , LL'iu
CERTIFICATION OF EXEMPTION FROM.WORKERS'l - 307 - INSULATI'ON '
(This section need not be comPlercN INSURANCE -_. .._... _..-._- ---._-_ _-- .-- .. . ....
COMPENSATIG -
"308 •, SHEETROCK� —'""'.
dit he pc no,is for onchundred dollars 309 - EXTERIOR LATH'
(51Wlarlcss.) r .
1., ❑ccnifY ihm in thq p<rfmrmnna of the work for which this p<�it is issued,e: - 3'1'0-"'— -INTERIOR:'LATH:, ;, - - - � -. ' .
mall net employ any person in any manna<n a,to beeme.object to the Workers 311 - SCRATCH COAT
Compensation Lbws of California.Date
Applicant 313 — ROOF NAIL
_. .
NOTICE TO APPLICANT If.after making this Cenifcae of Exemption.you should 501 - FINAL ELECTRICAL ENERGY
became subjectn the Workers Compensation provisions or the Labor Cnds,you mus
ZZO
romnwuhcnmplywitnsuehpmri.innanrmiapmitm.uxdernedreroked. _ - 502 — FINAL PLUMBING ENERGY. _
E, ^ `CONSTRUCTIONLENDINGAGENCY 503 - FINAL MECHANICAL ENERGY
C ' 1 hereby affirm thus there is a conswelion lending agency for the performance -
° IL`eader-lbbore.< �m 505 — FINAL ELECTRICAL ENE
fufine work forwldch mm ,tis tissued]see.309.7.Cir.C.) 504 FINAL BUILDING EN _ .
uder
U C) I certify than I have read miss application said state that the amuse iffnrmmdcn is 506 - GAS TEST
las"E:. co..Irs,mem comply with all dry end smarty oNismnces and sate laws relafing 507 — FINAL PLUMBING
O U to had wirig con.trmeti° and hereby aumadre representatives of this city it)enter upon 508 - FINAL MECHANICAL
>„'W the ahov>mentioned pmpeny for inspection purposes..,,
r4 (l1'elagree In a,,indemnifyand keeph.,mle,,,hb
may sthe City of Cupertino againn -
E. V. liabiliti(%Vol agree or sa .i and expensed which may anyvveyity fC upetgafnstlost 509 FINAL GRADE
UZ CI 'onsyuc oft Ar CO rthi it.
A DEI n1 co tLYWITH ALL o -Fol Issued ] NALdj�INING
REcuL YY� G
'm 9(A rant/C T r Date Re
Will
— ROOF PLYWOOD NAIL
Cwt y p goccuBDISCLOSURE Type Oi§Pelf- ROOF BATTENS
Will Mev h f or GOLI b MAT ecu t store O handle harsNuus mnmd:J - ... -.... ._—. .. - .
A A
as defined n the°ctt nine Municipal Curie.Chapter 9.12,and the Health and Safety 604 — ROOF IN-,PROGRESS
Code.Section 255321.)`.I. . . . , .a`-•L, . '
❑Ye's . ,.,pNp .; , •1, . ' -' __All roofs,shall be inspected prior to.any_roofing_material being installed._. -.
• ,
Will the applicant of future building occupant use equipment or devices w hich If a roof is installed without first obtaining an inspection, I'agree to remove
e
mil hazardous sir cnnumin.al,as defned by the Bay Arm Air Quality Management
District'? all new,materials for inspection. Applicant understands and will comply with
42 yes i E]No all non-point source regulations.
I have read the haearduus materials regnircm under Chapter 6.95 of the
.is Health A,Safety Code.See".,15505:' 5 and 25534.1 undemund thin -
ifthebuildingJces her, ti my responsibility to nmifythe -
occup t moron'en met of m'nsuance of a eni III of
° & Z C7/ ! Signature of Applicant Date
mnri.ed igen Dae All roof coverings to be Class •`B'• or betier
. . .. . . OFFICE