02040124 NO
CITY DGDVIn ENIISN PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21410 VAI AV LUDWIG ELIZABETH S 02040124
OWNER'S NAME: APPLICATION SUB DATE
LUDWIG ELIZABETH S 04/22/2002
PHONE: SANITARY NO. CONTROL NO.
1
0 i77 ARCHITECTIF.NGINEER: BUILDING PERMIT INTO
O O BLDG ELECT PLUMB MECH
yUz u
� i LICENSED CONTRACTOR'S DECLARATION
� I hereby affirm that l am licensed under provisions of Chapter 9lrommencing Job Description
IZn
B with Section 9000).&DivisionSofNcBusinessandPlofr,1 m1C.de.andmylicense CLEANOUT
m 5y is in full forme and effect.
O i U License Class Lic.ro
Date Connector
1;a.ri, ARCHITECT'S DECLARATION
1 undemmind my plans shall be used az public records
3 n 5p o Licensed Professional
OWNER-BUILDER DECLARATION
X A in 1 hereby affnn that I am.Rav� from the Commerce's o License Law for the
F z %hick lag mason Permit
]onstru Business and improve.
demolish,
h,or Any city or mauve $500
at O which rcquirte issuance,permit m romwa,nhec improve,demolish or repair any swoon
c3Po prior to,lts ensealso requitesthe m,folie;t for F,ha CoM1owmi's Licensle a e
Lawdvatemcm
the hbaccriemedpSectio 7"mun, of Division
of the C.mecmh License f,.(ma Cont9 t rs a• r,1 6 Valuation
(mhathe inemnip, ctionminadfebsisaof the Best nevemi Profession CoC;`�'`•J il'3' L 'IQ16 gait}:.rli i'`';
or that he is exempt thctdrom and the buns 6t the alleged exemption.Any violation
of Section]OJ LS by any applicant for a permit subjects the applicant to v civil Penalty-
of not more than live hundred dollars(S500f 106APN �R & WATER 1—' 1'' Occupancy Type
�I,as owner of the pr.peny,or my employees with wages as their sale compensation,
_
l�ill do the work.and the structure is not intended or offered for sale(Sec.70i4.
Basin.,and Professions Coic:The Common is License Low does not apply t.an 301 - ROUGH P *fti 4spections t -
.wner of property Who build.or improves thereon,and who does such work himself
.r thr..gh hie own employees.provided that verb improvements are not intended or .._ .__ 5.07 -__ L
FINA_ . PLUMBING_ -.. ..._. _ _..
;off ircA for sale.IL however,the building or impm
rovccm is sold within one yar eof -- -
completion,the bus mr,builder will have from home.of proving Nat he did nun build co
improve for porTe'a of sale.),
❑I,as owner of the _ n .. ..._ _... ._..__. _... ...-.._ . . ... _
prop= y,am exclusively contracting with licensed Contr cts m
icewn the project(Set,
appl it)a Business and Professions Code)The Convector's
License Law does not apply yr an owner.(property who builds or improves thereon,
.and Commeo..Lice. for such projecu with a.conwa.r(s)licensed puccuam to the .______. .. .... . . ... . ... .._. D . .a__.._.__ _.._.. _... ... ._. ... .
- ?
Commences Licende Low.
❑I um exempt under Sec. —By'&/P C for this reason rt.
ar H�L•"f"KER ICOMPENS IOND. LARAiIONZ G (� -
1 hereby off rm under penalty of perjury one of the fallowing declarations. \Y``INP^ 6 2��
❑ 1 have and will maintain a Cenifcac lei'Covent mself-insure for Worker's •1v �f•:
C...prnsation, as ,...lard for by Seeman 3700 oftheLabor Code, for the
performance of Ne work for which this permit is issued. , n
❑I have and will maintain Worker's Compensation Insurance,as required by Section `1
3700 of the Labor Code,far Ne performance of Ne work far which his permit is
issued.My Worker's Compensation Insurance carrier and Policy number arc:
amv ^ Policy No:
.CERTIFICATION OF EXEMPTION FROM WORKERS' t x I •- „l, Lst A *_ L 'k-'f• , - s- _• t
COMPENSATION INSURANCE •s' -
.. _ - __-__..._.._-._-..__.....__..,--------_,.__._._._._.__�._...___._.______.__.___._._._..._.__.__-._. ..
&This section need not be completed if the permit is for oar hundred dollars
(5101 r less.)
L ramify Nat in m.peHotmenm ultra work'&a which this permit is issued,l &1 v
shall not employ any perwn in sty r to
as hero a subject to the Worn ' " "
Appl
fonM1 comply eti sock' .,,his
n o 1 r
Com,emaiur Laxs oqf CoLff�nmi. c
NOTI aAPPLICANT.ILafter maki ,this Ceolume of Exemption you should
hero e.ubjen to the Worker's Compensation provisions of the labor Code.you must
Q O p y wi provisions nr his,matt>hall be deemed revoked.
F.en I CONSTRUCTION LENDING AGENCY -
a ; ''I batch,tiff.n Nei there is a comwnii.lending agency for he performance
;..; of the work for which this permit isissued(Sec.3097,Civ.CJ
Q Lrndcr's Name ... ..
.1. Z LrnAddress
V.Q 1 certify that I have read thio application and suite Nam
t the above information is
W E.; torten.ect.Iagree to c.mPIY with all city and county ordinances and nate laws relating
Q.V tohuildle censtrvcdooperty inspection
afthis city mercer upon
t: �] the abo(We)agree
property ify and keep
purposes.
homeless
F,; L es,judgments.agree to sane,indemnify and keep harmless the City of Cupertino against
W City in inntrance costs and m,ofexpensesi which may in,any way accme against said
C Z City in consequence R the grantinND WILL
derma. -
'•' APPLICANT UNDERSTANDS AND WILL COMPLY NTTH'ALL NON-PO I
SOURCE RI3 ULATIONS. �� Issued by: Date
St alure ofApplica r�ir •' to Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the b lir m e,furore building cu ant store or handle hazardous material _
rr glee h Type o Roo . . .. ... .. ..... - --as defined io the Cupertino Municipal Coda Chapter 9.12.and the Health and Safety -
Code Section 25532(a)? Nn I`^?:, f r a s . : t , it
' - _ -_ .All roofsshull be mspecteIII 6r tn,any.roofing.material_being,installed..
Will flicapplicameor future wilding occupant useen,cApormileadevices which If a roof is installed without first obtaining an inspection, 1 agree to remove
emit ham
eote
.. r cam minams in defined by the Bay Arco Air Quality Management
District? all new materials for inspection. Applicant understands and will comply with
.Yea V N. all non-point source regulations. '
1 have and rhe ha r dens mincrial oofircmunts under Chapter 6.95 of°the
Califomi.Health&Safety Code.Sections 25505,25533 and 25534.1 undersand Nat
if the building does not currently have atenant.that it is my responsibility to notify the
occupant of the requirements which must be met prior to iseance of.C III[ f
Occupancy. .. )
Signature of Applicant Date
_ nmm�.th.ri,edagent /f ate All roof coverings to be Class "B"or better
:. . . . OFFICE