04080221 CITY OF CUPERTINO '�
BUILDING DIVISION PERMIT wGONTRACTOR INFORMATION
BUILDING ADDRESS: BANGERT STEVEN N AND BETH ERM rNo04080221
OWNER'S NAME: - PERA9TISSUEDATE
E:
SANITARY O. C N ROL NO,
ARCHITECT/BNGINEER: BUTWINO PERMIT INFO
BLDG ELECT PLUMB MECH
] 0 t�
yOZ' LICENSED CONTRACTOR'S DECLARATION JobDescri tion
Mti 1 hemby affirm that I em IImm d under provisions of Chapter 9(Commencing p
with Section 7")of Division 3 of dm Business and Professions Code,and my licento Is
pN in full form and Affect. POOL DEMO
j n Z Lleene Das Lica
Dam comractor
,eARCHITECTS DECLARATION
y U 1 understand my plans Mall he used As public records �<
02
Licensed Professional O.^
3 OWNER-BUILDER DECLARATION Y
N /
1 Mrehy.(Sero that I 1 exempt from the Collinson Licenseny c Lew for the
00 which
grtresa Permit
t 7fUL4Buainersand mpr ve deione Code:Any tiny or county /
$ which requires a Permh m c 1. ct,alms improve,Jc Permit
,a c A.ir any aaunnw
Pd.,m its ceased e,atm requirer the apPliunl Tureen permia m Ric se signed stammem
(chat tre ommencing
accensed punuam 70th)of Divioernf the a Buacms and prseLaw lC Code)
Sq.Ft. Floor Area Valuat on
'met
exemttSution from 7000)ofbasis for
themBusiness and proportions Any violation
or
$ Net io 7 campy therefrom and the bub far the subjects
thalleged eemant in Any l genion of
Semon 7031.5 by any app'.Tuna fora pump Subjttu the applicant m e civil Paminy of 3 9&AIM"gr0 0 Occu ane ryR
- 0an roam manmanfin halhundred dollars($50B. p y pep/Y'
Q 1,An owner of the properly,or my employees with wages as their sole compensation,
will do The work end the structure is not intended or offered for sola(Sec.7044,Business
and profession Code:The Commences License taw does Act apply At an Owner of Required Inspections
property who builds orimpro rm themen,aMwho doersmh workhimtelf orthrough his
awn employers,provided that such improvements are not intended oroffered formic.If,
however,the building or improvement is sold within one year of completion,the ownu-
buiklm will as.the burden of proving Nn he did nm build or improve for purpose of
sel.j.
Q 1,u owner of the property,am exclusively contracting with licensed conuacmn to
comtmct the pmjmt(Sec.7044,Business and Profersiors Code:)The ComnMfs Li.
came law docs not apply no an owner of property who builds or improver memon,and
who contracts for such projects with a comracter(O licensed punuanno the Contractor'.
Llmom
W.
time
in under See. .B k P C for this rteaan
Ownertwk
Bna�{
WORKER'S eOMPFdNSAT1ON DECLARA'PON
I hereby affhm under penally of perjury ate of the following declarations:
ve and will maintain aCer iron m of Consent self-insure for Workers Compcn.
an,haas Provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
Q I have and will maintain Waken Compete m.Inaunnce,as nquirtd by Section
3700 of Ne labor Com,for the perfomance of the work for which this Permit is leaved.
My Workers Compensation Insurance carrier end Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisseceon head not he completed Rare permit is foronc hundred dollars(SIM)
or loss)
1 camify,than in the perhomanec of the work for which this permit is issued.I shall not
employ any person in any manor An as m becomesubjmn to the Warted'Compenudon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,After making this Certificate of Exemptian,you should
become Subject m the WO Offs CamPensallon provision of me labor Code,you mum
O forthwith comply with such provisions or this Permit shall he decmW revoked.
z'"' CONSTRUCTION LENDING AGENCY
wt%1+ IMmb affirm that mart is a Comnche.Imcin a
F Y g mruY l'ar me mrfurmantt of
Ci me work for which this permit Is issued(Sec.309's,Civ.C.7
a Q LeneName
=z lander'.Address
V 0 1 certify than 1 have read this application and state that the above mo nnluh is
F correct,
Iagree be comply with all city and county ordinances and ser¢laws reining to
>0 building construction,And hembyanhorirarpose. tativrs of this city mcnmr upon tite
6Wi above-(We)Are Progeny for insindemnify
Ad keep hs
(We)Agree to save,indemnify and heap May
in An the City of Against against /�
nFa y liebilirer,Judgmcnta.coau and espcnacs which they in any way accma ageinsueid City //�,
U z me venae oft granting of this Permit. t-hV/
APPLI NT UNDER57ANOS AND WILL COMPLY WITH ALL NO Issued by: da Date r
SOUR ATI S.
gi
I Re-roofs
igd tura of Applinm/Conscmr DA
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fumm building Occupant stun,or handle hanrdovs mamnal
As defined by dte Cupertino Municipal Code.Chapter 9.12,and tlm Hulce and Safety
Code.Section 35332(e)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes to
Will the applicant or forum building oecupant sex equipment ar dcvirrs which If a roof is installed without first obtaining an inspection,I agree to remove
harsrdous air contaminants a defined by the Bay Area Air Quality Mahegcmma all new materials for inspection.
❑Yu
I hove mad the harallous materials requimments under Chapter 6.95 of the Califon
aria Heal d:Safcry Code,Sections 25505,25533 an!25534.1 understaM mu if the Wilding
does nor urremly haw•tenant mat it is my responsibility m notify the omvpant of dm
reqMApmBtMdorm acrcea(.CAnlremafOccupancy. Signature of Applicant Date
Ow rorauthorixdagent Dam All roof coverings to be Class "B" or better
CITY OF CUPERTINO ANIL
BUILDING DIVISION PERW C ONTAA CTOR'JNF
7Z ";7
BUILDING ADDRESS: BANGERT STEVEN N AND 13L,1H "0 4 0 8 0 2 2 1
IOR49 WTTKTN20N 4.11 PERMIT ISSUE DATE
OWNER'S NAME�
RANGERT STRVEN N AND RETH SANITARY 9,8,12 5 X 2�ft OL NO.
PHONE:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
coo LICENSED CObnRACTDR`S DECLARATION VVkLnr U
�Icir I hereby affiron,that I am licensed under provisions of Chapter 9(commencing
�U' , andenylicarescis
z, fth Section 7")of Division 3 of he Business and PrafiessionsCods,
in full force and effect,
POOL DEMO
nj1Z License Class—Lie.0
Z�aa Dart—Contractor— DEC L29 2004
ARCHITECTS DECLARATION
I understand my plans shall be used za public monob,
U I L G
Licensed Professional
OWNER-BUILDER DECLARATION 04
I bunchy art.that I a.coarnp,from ft Contractors Lancre.Law far the
following mason.(Scation 703 1.5,Business and Professions Code:Any city or county
which requires.Permit to consumer.alls,improve,dicamilibith.or repair any structure
ad
prior in its issuarrec,also mulumas the applicant for such Perim'to filc a signed sufacavent Sq.Ft. Floor Area Valuad'olno 0 0
fliat k m licensed pursommuct the provisions of off,Contractor's License Law lChapter 9
(commencing with Section 700ft of Division 3 of the Business and PendfiessionsCode)Or
and las Is inuarapt dooreftorn and the basis far dan alleged asurroplich.A.,viminfinin M
Section 7031.5 by say,applicant far a permit aubjects the applicant in a civil Penalty of 3 96IN3*0"ero 0 Occupancy:rype
Out more thad fi.hundred delta.(S!Ks[d.
will do the work.andoic incomes tricoomemkid arroffered for sake,(Sec.70s4.Business
and Prodesumn Codc:The Cmicanothen License La.does fou apply 1.im.waal Of Required Inspections
properny who builds of militaries comaran,and whodoca such work himself orthrough his
own employees,provided chat such Improvements rumnot intended oraffiered!forsale.If,
havever,the building orrimperverment issold widunome rar orcomphation.the owner-
builder will have dine burden or proving that he did not build or improve for purpose or
0 1.res Owner of che Prurient,am exclusively Ciontracting with licensed andurearchat to
(nounnion Our project(Sec.7�.Bashi and Profession$Cada:)The COOMerhar's Ui-
across,Law does not apply to an owner of propery who theilds or improves darecon,and
who connotes for such prepeca with a conerachou(s)licensed purathool to dua Commookon's
License w.
a raptiandroSec B&PCroardiencitiorn
WU
RKERS UiDMPl4NSAI RJN UMI—ARAT)ON
J I hereby afford under penaily of perjur,ame of da,following declandiona
0 1 Kinve and will mandain 2 Canufficam,olConsen,a self-urear,Are WinlareaCompon-
When.as provided for by Section 37M of the Labor Code.for be performance of the
Fork far which this permit is Issued.
0 1 think and will repainumn Wei Compensation In..,as obtained by Section
37W of the Labor Code.for re,Kohnionance otche work for which this Profit is issued.
My Warker's Corn,ransiont Insurance carrier and Policy number sma:
Carneo Policy No.:
CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
mas section mad traffic,completed if the paranift is for...hundred 011.(SIM)
or Is.)
I century that in the performance of do,work for which this permit a issued,I shall not
employ any oosson in any manner an as an Income subject to the Workers Compensation
Lawsm California.D.
Applicant�
NOTICE TO APPLICANT-.If.after making this Cerificau,Or Eacerption,you should
zWeems subject so the Warlon's Compensation provisions of the Labor Code,you main
landwith comply widi such provisions or this permit thaft Ite dicamand mooked.
z
E�8 CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a concoureactinn lending agency for chic performance of
ths,work far which'his Fermi,is issued(Sea.3097.Ci,C.)
La thin's Name
D z Looda,.Addres,
u 0 1 century that I have ad this application ad same that due above information is
contain.I.,.,to comply with,all I,,and comedy mofiranceircrod tabe laws noWing to
0 U building innercomfion.and hereby authorins representatives Of data City to ander upon the
W idarmi-impli...d property far inspection.piapposua
0L. (Wer)agree to save.indemnify and Imcp harmless the City of Carpathian against
v) firibiladco.judgments.costs and expcouris which may in any way acome,against said City
in a.1
A Ll�.c.s.17diallocifingafthilromfol. i,
PPLI Abo"UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR&R�IULAT'
.1 / ___ �� t* Re-roofs
fSigpdrurc of ApploodithoCon"ah" IT Day
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will 00 applicant Or future building moupant store or handle haicrothours normcnal
as dcrincd by the Cuperion,Municipal Code.Chapter 9.12.and the Hcalso and Safety
Code,Section 25532(a)7
C]Yes ON. All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection,I agree to remove
Will the pixion,or for..building exceirpod,us,equipment or devices which
emit havandmis air comearrinams ar refined by the Bay Area Air Quality Management all new materials for inspection.
I havencial�c�?ardc)usmawri2lsmquimmcnmundcrChopmr6.95of�Caliror-
ma HealS�Sdc,,YC�c,S.�.n�25�5,25533 sue.125534.Imiderstand hardfou,lonatfir,
due.no"uniand have.union.bad it is MY netramadmildY W Mary fle fortiroint Of da�
as h h fOccuparcy, Signature of Applicant Date
OZE— I�=e 17 All roof coverings to be Class "B" or better
v,h6,.raudhMi.d agent Do.
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CITY OF CUPERTIlV
a DEMO
CUPEkTiNO PERMIT APPLICATION FORM
APN# ✓ f 7 �r Date: c�
✓ / I
Building Address: G \
Owner's Name: Phone#:
S ev e� A� erg 40Fs_.!�Ls F0
Contractor: r License#:
5e�f
Contact: Phone#:
J
Applicant/Contracton �Q
Building Permit Info:
Bldg Elect Plumb Mech
Job Description: (
Residential: �G CJ c1 e 1M Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation: J
Type of Construction: Occup GLp: i
• Qt if
A is le Fee ID Fee Descril2tion Fee Group
BPERMFEE Bldg Permit Fees BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
BSEISMICRE Seismic Residential - BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG