02080143 OF
cJBUILDING DIVISION
PERMIT CONTRACTOR INFORMATION-
BUILDING ADDRESS: PERMIT NO.
10447 VISTA KNOLL BLVD 02080143
APPLICATIONSB DAT
Ask°\��^lMMILLIAM R AND DANA L 08726/2002
( PHONE: SANITARY NO. CONTROL NO.
t
MoO O ARCHITECTENGINEER: a BUILDING PERMIT INFO
F BLDG ELECT PLUMB MECH
a z`� E_J
tai
5 H Z LICENSED CONTRACTOR'S DECLARATION Job Description
0ZEl a 1herebyaffirmthat1amlicensedansaprovisionsofChaper9(commencing BATHROOM REMODEL
Fin t- with Section]OW7 of Division 3 of the Do me
nJ Profess ions Code,and my license
ase— m ran ro ana ertee _85" .S
z eco n Date Rn 7 Licrastnt[' /
ia c LL Date ARCHITECT DEELARATION FIN N rte q a.�13
g 1 veersund my plans shall be used a public records Y
Y
tip O Licensed Professional } 0 02
Koh OWNER�BU ELDER DECLARATION CES 1 20LU
.!2 m 1 hereby affi.that 1 am exempt from the Contractor's License Law for the
F Z a following rearm.ISectinn]U31.5.Business anJ Proressinns Calc:Any city or county $2900
Ix0
whit h q permit m t t llr.improve,demolish,.1caP y .,Tom
i 3 E
pri itsnc also darn.,the a,licam,f hpe Oo rk gn d startarrandb - • ..._- - _...-._ __ __ _._.__. -
tRtfhe is I 'll;dPrn:urTttothe p fthe Contractors License La (Chapter 9. 3AIF3;d�3���0 1 Valuation
(commencing with Section 7MI of Dlvs n3of me Ba"..add Professions Code) 1 ;iI^! r i„ _ .•, _ sri..i . . it�:\t.
or Nat he'is exempt tnemfmm•dnil the bass for the alleged esamptiuo.Any violation
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty Occupancy
of not more than Five hundred dollars(S50% 101APN VOPtNDAT ION P Y Type
0 1.as owner of he praporty,or asy employees%ith wages as their role compensation, 102 - PIERS
-will do the work:and the atachure'is not intended or offered for sale(Sec.7041. 103 - UFER Required Inspections
Business and Professions Coke:The Contractor's License Law dues not apply m an 9 P
.net of property who wilds or impwvea thereon,ana who does such.ark himself 104 - REBAR
or through his own employees.provided that such improvements are not intendedyear of _
-"co ple for sale.If,however,the building or improvement is what he did one year of 105 ANCHOR- BOLTS'
omove,fa.the ownerwildcr will have the when of proving that he did not will or 106 - SEWER & WATER
improve for puryose of sale.).
- - 202 - UNDERFLOOR PLUMBING- -- r - __. .
❑I;as owner of the property,ant exclusively contracting with licensed contractors to -
construct the project(Sec.]0.W.Business and Professions Caac:)The Cantmaor•s 2 03 — UNDERFLOOR MECHANICAL -
License '
Law does not apply to an owner of property who builds or improves thereon.
and who contracts for.such piojerls wiM.a contractors)licensed pursuant to.ma" . ..-...204 ---UNDERFLOOR-"FRAME_ -...-.----... .... - .
o 1..c°e.pttcunder U.
.B&PCbar Mis maven 205 — UNDERFLOOR' LNSULATION
_ owner 301 — ROUGH PLUMBING
7 'WORKER'S COMPENSATION DECLARATION 302 — TUB & OR SHOWER
Ihereby affirm under Penalty ofpeijmyone ofthe following declinations: 303 — ROUGH MECHANICAL
❑ 1 have and will maintain a Certificate of Consent to self-insure for workers 304 — ROUGH ELECTRICAL
Compensation, as provided for by Section 37W of The Labor Code, for the 305 - FRAME
_ perfonnanae of the work for which this permit is issucJ. ,
❑1 have and will maintain Worker's Compensmion Iniumnce,as required by Section 306 — HOEDOWNS
37W of the Labor Cose.fol the performance of the work for which this permit is 3 07 - INSULATION
au d My W ked Co pe i Insurance carter odd Puhcy number are: ..y,..
q . 308...— -SHEETROCK
S t:6; 9 wlvyN 2V7t7-3f;a-2o0Z n -30'9 " = EXTERIOR"LATH
a
FICATION OF EKEMP'NOII FROM WORKERS
coMPENsnnoN INSURANCE _- --- 3-10,,--.-INTERIOR-LATH-'.._. .
(Th s section need not be romplcoud tribe permit is far one hamlred dollen 311 — SCRATCH COAT
alWlaness.l 313 - -ROOF...NAIL. :.... ._...
" I'ecmfy that in The performance of the work for which this resent is ew a issueI' 501 — FINAL ELECTRI CAL ENERGY
shall not employ any person in any manner to became m e subject the Wssfka,rs'
Compensation Law.afeallrnmia.Date 502 . — FINAL_.PLUMBING. ENERGY
_.Applicant.
NOTICE TO APPLICANT.If,ader making this Certificate of Exemption.you should 503 - FINAL MECHANICAL :ENERGY
became subject to the Workers Compensation Provisions of the Labor Cak,you must
Zmnhwithcomply with such provisions orthis permit shall hedeemed revoked. 504 —. _FINAL BUILDING ENERGY _
V1 ' ..t CONSTRUMONLENDING AGENCY SOS -. -FINAL ELECTRICAL
1 he by 1r m thin there oat i leading agency for the performance 506 - GAS TEST
•of the work for whichm p rtt is 6rd(Se .\09] Civ C.) - ... .. .
y z Under
Name 507 — FINAL PliUMBING
a Address50 — FINAL MECHANICAL
'U O 1I idmifyace met l p e rod this city
a i n my ordinances
mann oboe fo re ati lis 5 9 - INAL GRADE
fes F., correct 1 agree to comply with all city anJ county ordinances and sue laws relating
tohaddingconsmaction.and hereby authoriaereprescmmivesofthiscity,.enurupo 5 0 — ZNAL ANN NG
the above....crowned property for i.%eceon Patroclus
. .
yDKclagreemmve.indemnify and keep wmnlesstheCity ofCupcninoagainst 5 - INAL RKS Q
Fin liabilities,judgments.costs and expenses which may in any way decree against said 7O
r> z City in consequence of a graining of this permit. LV /
APPLICAN UN ANDS'A:VwILL COMPLY WITH AL NPONT Issued by Date Uv
5 URCE P U Y
ignamre ofA plea vcm attar " DateRe-roofs
A OUS MATERIALS DISCLOSURE
'w,n'lne appnFanto uurc building occupant voce w handle heaallous mquriil Type of Roof.
as carried b$me Cupertino Municipal Code.Chapter 9.12,and the Health and Safety „s .• y -
Code,Section 25531001 tl'l - l"i s :x sl} t '• as •'�:1,'.i. r. t ) `it.
'OYc" t 11'P(Na .j"
All roofs shall be.inspected prior.to any roofing-material being installed...
Wdl the applicant or future building wcupant asacquipment ordevicas which If a roof is installed without first obtaining aninspectitin,"I'agfeeto.remove
emit haraddous air contaminants as define by the Bay Area Air Quality Management
Diad,.? all new materials for inspection. Applicant understands and will comply with
❑Yes- AL No all non-point source regulations.
I have read the haiardaus mntde
edals ca,mmmem,unr Chapter 11.95 of the
Cillfomlu Health&Safety GMe.Sccilcas 25505.25533 and 25530.1 understand that .. .. ._ . .
if ibe willing does not cunently has<a tenant.that it is my responsibility to notify the
occupant of th qa'. 'at hich moa be me prior to ism...c of a Certificate of
'• ' Occupircy' Signature of Applicant Date
own dam ri Data All roof coverings to be Class"B•'or better'.
-•, :r.
OFFICE