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03020026 CITY OF CUPERTINO BUILDING DIVISION PERMIT ,C0NTRACT0RINF0RMATI0N., : LSF BUILDINGADDRISS: ADF CONSTRUCTION PERMIT NO. 10873 WILKINSON AV OWNER'S NAME: 6201 SHADELANDS DR APPLICATION SUB DATE Awk PANNELL DONALD R AND CHARLO TE 02/07/2003 Or"E' 4082819177 SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INPO BLDG ELECT PLUMB MECII 0 0 0 0 �00 LICENSED CONTRACTOR'S DECLARATION U I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description wbb SoctionlrOky)tit D'viainn Sof NC Ousinc and PnncuinnaGdc,and myliccnu is EEE in fullfnrccand-� R k - D REPLACE SHAVER & VANITY License Class Laii.Intxsyap�t// fpm. 1m1`a`II ® 1� F?F� Da¢ ARCIII'I'IiCPS(]�`,1. 1 N a �a arr `�rAak ED y< adcuumm!my plans shall he used as public records t�iit FEB 2 7 2003 LLor License)Pmfcssiunal - j OWNER-BUILDER DECLARATION CLARATION u�<f I ncrchy allinn Nm 1 am cam.Pt from the Cnnounor'S License Law for Nc w—❑O following reason.(Section 7031.5,Business and Professions Cade:Any city of uemy BUILDING which requires a permit to construct,alter,improve.demolish,of repair any mructum prior to its issuance,also requires the applicant for such Worninu life a signed statement ~ G that be is licensed u notto the provisions of the Cont.no,'s License Law(Chapter S Ft. Floor Area tion p rs p n� ( p q. $11YAb3© (commencing with Section r (Xdand of Division 3 of the Rosalleged miss and Promsns.An inns Codc)hued a, � Out he is exempt Ncmfmm and the basis for Nc ellcgeJ cumptinn.Any violation of Section 7031.5 by any applicant for a Permit objects no,applicant to a civil penalty of u Occupancy Type not more Nan five hundred doll..($501). ❑1.as owner of the property,or my employees with wages as their sole compensation, will do the work.and the structure is not intended or offered for sale(See.7044,Business and Professions Code:The Contractor's License Law does not apply to an owner of 102 - PIS R S e ulred Inspections pmpeny who buildsnr improves Nercon,and who doessuch work himself or Brough his own employees,provided Nat such improvements arc not intended mallard for sale.If. 103 — UFER haws.,,he building of improvement is old within one year of completion,lie owner, builder will have the burden of proving Nat he did not Wild or improve for purpose of 10 4 - REBAR sufie) 105 - ANCHOR BOLTS ❑I,as owner of the p,.,my,am caclusively enameling with licenced undsomme,to 106 - SEWER & WATER consumer the project(Sec.7044,Business and Professions Code:)The Con rmfor's Li. wtense Law does not apply to an owner of progeny who milds or improves Bannon,and 202 - UNDERFLOOR PLUMBING ho contracts for such projects with a c°mmermbs)licensed pursuant In the Contractor's 2O3 — UNDERFLOOR MECHANICAL License Law. ❑I sat cumpt under Sec. ,B&PC for Nis reason 204 - UNDERFLOOR FRAME Owner Date 205 - UNDERFLOOR INSULATION WORKER'S COMPENSATION DECLARATION 301 - ROUGH PLUMBING I hereby affirm under penalty of perjury one of the following declarations: 302 — TUB & OR SHOWER �.. 1 have and will maintain is Cenificare of Conserv to self-insure for Walker's Compere smion,a.provided for by Seefion 3700 of the Latin,code.far the performance of 3 03 - ROUGH MECHANICAL work for which this Permit is issued. 304 - ROUGH ELECTRICAL 1 have end will meinwin W°rkcr'a Compensation Insurance,a rtyuired by Section 3 0 5 - FRAME q1 of the Labor Calc,for the performance of the work for which this permit is issued. My Workcis Conditionalion lstamns,carrier an,Pam umber am: 306 — HOLDOWNS came,: S}zl YLthe� POBcy� I123i1- 100 307 - INSULATION CERIIPICATEOPEXEMKIONPROM WORKI?RS' COMPENSATION INSURANCE 308 - SHEETROCK musseNonneedna be completed if Ne leumit is for one hundred dollars($100) 309 - EXTERIOR LATH o`lea`) 310 - INTERIOR LATH 1 unify list in the performance of the work for which this Permit is issued,1 shall not 311 - SCRATCH COAT employ any Person in any manner so m to become subject to the Workers'Compensation Laws of Califomia.Data 313 - ROOF NAIL Applicant NOTICE TO APPLICANT;If.after making this Cenilicae of Esempion,you should 501 - FINAL ELECTRICAL ENERGY become subject to the Worker's Compensation provision of the Labor Code,you must oZ forthwith comply with such previsions orthis Permit Oallhedeemed,csolou. 502 - FINAL PLUMBING ENERGY Z 0 CONSTRUC 10NLENDINGAGENCY 503 - FINAL MECHANICAL ENERGY I:. = Ihereby aNrmthat 0creisaconstruction)ending agency for the perfoomuccof 504 - FINAL BUILDING ENERGY 119 the work for which this Pctmhis issued(Sec.3007.civ.Cd Under's Name 505 — FINAL ELECTRICAL W Q =)Z 506 506 - GAS TEST UO 1unify Narlhave mind NiaappIndia.and smethat the above mmm.donis 507 - FINAL—PLUMBING W F correct.l agree to comply with all city and county oninroces and some laws refining to DU building consuaction.and hereby moronic mimsennitives of this city to enter upon the FINAL MECHAN CAL W aMve-mentioned pmpeny for inspection purposes. O9 FIN W (We)agree m save,indemnify and keep barmlea the City of Cupenmo against f/1 liabilities,judgments,costs and expenses which may in any way accrue against said City 55 G in of the gaining of his peonnit. U APPLICANT UNO[Rti IANDSIAND WILL COMPLY WE A NON-POINT Issued by:5 WORKS Date SOURCE R QULATIONS. , 7Z Re-roofs um f t` ors I IIAPARDOUS MATERIALS DISCLOSURE DL Type of Roof Will the applicant or future building twcupenl store or handle hvrallous material az debbed by the Cupertino Municipal Code,Chapter 9.12.and the I lealih and Safety Code.S:Iyca zss32(a)T All roofs shall be inspected prior to an roofing material bei. installed. ❑reso P P Y g g Will the applicant or future building occupant use ryuipmem or devices which If a roof is installed without first obtaining an inspection, I agree to remove nit hamN°us air unumainan.as defined by the Day Arca Air Quality Management all new materials for inspection. D'stricq ❑Yea 1611 I have mail the havardousmumrials requirements under Chapter 6.95 of the Califor- aiallcalN&SafieryCab.Sntione25505,25533 and 25534.1 demand Nmifbe budding Boca Inn cure have.tenant,Nat it is my respomilolity w fy,t xspot of she ` re 1"'I 1C4 ham" `" 1— a, 7/0 3 Signature of Applicant Date Owner mort.<d agent Do All roof coverings to be Class "B" or better