01080064 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMi r NO.
19702 VICKSBURG DR IWAMOTO RICK M AND KAREN L01080064
G �J � OB DATE
RICK M AND KAREN L APPLICATION
PHONE: SANITARY NO. CONTROL NO.
C¢zARCHITEC(ENGINEER: BUILDING PERMIT INFO
y O BLDG ELECT PLUMB NIECH
Lai CI LJ I.J I� 1
yj
Z 5 v Z LICENSED CONTRACTOR'S DECLARATION Job Description
o _oI hereby affirm mat I am fcensed under pmvismna arenaprer 9 commencing BATHRM REMODEL.
w with Section 7000)of Division 3 of the Business and Professions Code,and my lkcase
z m is in full forec and efleo,
a License Class Lic.9
de U Date Contractor
t-lL o n ARCHITECT'S DECLARATION �'yam, /� ���
v T g I understand my Plans shall be u.wd as public reroNs ,M A
i S z Licensed Professional
�oN OWNER-BUILDER DECLARATION NOV 1 3 2001
I hereby um Th
ffral 1 am exempt fruit,the eumrwcu's License Law for the
F Z a following reawn.(Sation 7W 1.5.Business and Professions Code:Any city or county• $32000
xH e which requires n permit to amamct,alcor.improve,demolish,or repair any amcmre
i 3.w pro,to its ieamncaalso requiresthe applicant forsuch perms In flea sigrcd statement -----
that hei:licensed panurnlbit the prooson.rnthe Contor License Law(Chapter 9 '
'36 1�f0F1�r Valuation
(commencing with Section 70(10)of Division 3 ofthe B®mess and Profea6...Coda - 1
or that be is exempt therefmin`anJ the basis For the alleged exemption.Any vrotation
of Section 703 1 i5 by any applicant for a Permit subjects the applicant to a civil penalty
.of rim moreteam five hundred dona.(55an. 101APNVWU1TDATION "< Occupancy Type
❑Lasownerar mepmpeny,nrntyemployeeawnnwasesasmehsolecampensadat,. 102 - PIERS
will do the work.and the s memre'is not intended or offered for sale(See.7841,- 10 3 - UFER Required Inspections*
'
Basinsin ami Pmfeaion..Code:The Comcarmrs License Taw doe:not apply to an 9 p
owns
r at property Who builds or improves thereon,and who does such work himself 104 - REBAR
or through his awn employers.provided that such improvements are nm intended or __ _
oourplefor sale.ILhobuildethebuilding or burden
of proving
sold he did We Wild or -' - 105 ANCHOR- BOLTS -
m6ptmifrmevi,cofbaah,l) will have theWNcnufpmvingthathedidnotWillor 106 - SEWER & WATER
improve puryase u
r�:�dawd«ofine'amxr:5me:eLdi lre;.d tikes-niceeonGafrve' " 202___,_UNDERFLOOR -PLUMBING-- - _... .__.-- -..._
construct the project(Sec.IGNI.Business and Pmfe..mns Code:)The cantracmrs 203 - UNDERFLOOR MECHANICAL r' '
License Law does not apply to an owner of pmpeny who Wilds or improves thereon,
-and who contracts for such projects with a contmctods).Bcerced.pmsuant to the --- 2 04 ' -- -UNDERFLOOR FRAME- - -- -
Cuntracmr's License Law. a -'- -- -
❑lameset,tptan sea. `B'asPcetrmisRawn 205 - UNDERFLOORt,fNSU'LATION
_ Date 301 - ROUGH PLUMBING
WORKER'SCOMPENSATION DECLARATION 302 - TUB & OR SHOWER
Ihereby orerm;neer,penaltyofpeja,mric.ofinernnowingdearona:<lat303 - ROUGH MECHANICAL
❑ 1 have and will maintain a Cemfirme of consent to self insore for Warker. 304 ROUGH ELECTRICAL
Compensation. as provided for by section 37M or the Labor Cade, for the
permit puftoranee of he work for which this is issued., ,, 305 FRAME
❑1 han and will malnmin Worker',Compenmtim Inemnce,a required by Section 306 - HOLDOWNS
37W of the LebuT Code,liar the perlourno.of the work far which this prrmi,is
307 - INSULATION
Iss`ud,My Wk .'C , pe . t In.wm¢e came,and Poly bore:
-, e -- _„ . . 308" -:SHE4TROCK. _.. .. , ._
Cart ) .Policy No. - t .
'CERTIFICATION OF EXEMPTION FROM WORKERS, 309 EXTERIOR LATH.
' -COMPENSATION INSURANCE,
_ 3.1.0_;_ INTERIOR--LATH` ----_- ..-- , -------- __..._ _..
.iI
(This eecubn' Jnat bL mntplcnJ lthe permiti.fr ate Wnared anuar` 311 - SCRATCH COAT
-
313 ---ROOF, NAIL
I c n fl tkn the nein mance lar k f n nth.period, x ed'I 1'
Cdoll ompotcmplayanype: nany sDatenne a.t6.e.11 Applicant . ..1 s;the waters 501 - FINAL ELECTRICAL ENERGY
❑ n rat,Laws (cfmrnia.Dma 502 .-. FINAL.-PLUMBING. ENERGY. .. .
NOTICC TO APPLICANT:If.arteromking this Ccnifi.`menf Exemption,youxhould 503 - FINAL MECHANICAL ENERGY "
become wbject io the Workers Compensation p
O ZO mnhwdnenmplywansarnprswi.sonsorm'tsp�nnohuotbadeeneJrCode,
kdamast _ 504 - FINAL BUILDING ENERGY
Z2 -- - '- - - - -- '- '- - .. .. - -- ---- -- ...--
Z) CONSTRUCTION LENDING AGENCY 505 - FINAL ELECTRICAL, ,,
Inctebyanimimmmeretsa�onstmefonlendmgpsenryforthcperraimance 506 - GAS TEST
• .. of Ne work for which this Permit is issued(Sec.31197,Cie C.) -.. .._. .. . ... .. ..... ._ _ .. -
d.q 'Lenders Name ,-- ..: - . - . _.'. .. . . .. - 507 = FINAL PLUMBING. .
'Lent Addtt
U.
milt, am' v6h t d temtm W ' r 508 - FINAL MECHANICAL
OF 1. 1c t l g t ply. n nc d y d' � d ct ldilating 509 - FINAL GRADE �'GIQ
O0
.U stab Id' s constraction.andhereby ruthorizerevs_ t t of ty to enter upon 510 - FINAL PLANNING
Iy theabove
-mentioned property tinspection p id :c. y,
E �
],shuttle,. ax eto t dd ,fyasd keel nPhnr„Y.n con City yrut apertm ingainst 514 - FINAL PUBLIC WORKS / /
U z C y e4 enc[ ftp g t o D
APPLICANT UNDERSTANDS ANDWILL COMPLY Wil HALL NON-POINT Issred b Date
SOURCEAT)O�. -'', y 8-/5. Y'
:• .SigwmrcutAAppllcamlCounJsccour Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE.
.,'9:
Will ttheappllcaut or,furore building occupam store m handle hazaNnus mmenal Type of Roof
esdefnedby the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Cede;Section
oys 25532(ah :r',C�a.t;'. t
�• '' •' All roofs shall be inspected.prior.to any,roofing material being-installed.__ ..
' w-B theapplicantor future buildg occupant useequpmemmdevme. nth If a roof is in''Ialled'without first obtaining an inspectlon,`I,agree-to'remove
emit hd air com nt t as deficedby the Bay Area Air Quality Nmog• seer
District? all new materials for inspection. Applicant understands and will comply with
all non-point source regulations..
1 have read the hazardous materials,requiremcnu funder Chuprer 6.95 of the
Culifunia Heahh S,Safety Cale,Scctinns 25505,25533 and 25534.l and...land thin
if the building does not currently have a tenant.that it is my responsibility to notify the
occupant of the requirement,which must be met prior to is.mm,c of a Cenificzre at
Occupancy. y. .
Signature of Applicant _ .. .. _, - Date
Owner a.aamadzed agent ,. : Date All roof coverings to be Class `B" or better
Ar�.. r. . . .,_-. . . _ .. .
OFFICE . . .