02100182 (3) CITY OF CUPER'1'INO ""
BUILDING DIVISION PERMIT CONTRACTOR"INFORMATION:
as
BuJJD&490aEsFLORENCE DR DYCKMAN TERRY A AND BREND PFOlo"'N92100182
15Y!12q MIIAN TERRY A AND BRENDA S APPLICAT!PnsS B"N2002
PHONE: SANITARY NO./ / CONTROL NO,
ARCHITECfIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
f00 LICENSED CONTRACTOR'S DECLARATION "^7
F I hereby af0rtn that I em licensed under provisions of Chapter Y(commencing �/� }T�f �T�sr�2�Tlp
with Section 7lXYBnf Division 3 ofthe Business and Professions Colic,and my license is KI CHEN ,REM - " •"'ll�
FOin in full Imen and olfoer.
ZOga License Claxs Lic.A i
OZ� Dale Contractor ^^-
F� ARCHI TSDECLAR ATION
1 understand
WEnd my plans used as public records
O�V
F
Licensed Prnfcssional
Be C
OWNER-BUILDER DECLARATION
y 1 hereby affirm Thal 1 am exempt from the Contractor's License Law lin the r
uhf a O following maxua(Section 71131.5.Business and Professions Code:Any city nr county
$(< which requires a permit to conslrun,alter,improve,demolish,or mono any structure
prior m its issuance,also requires the applicant for such permit to file a signed summon,
€� that he is focused pursuanuo the provisions of the ComracnMS License Law(Chapter 9 3S46136FE15dn A@0 Valuation
$ (commencing with Section?(XXB Of Division 3 of the Business and Professions Code)or
Out he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of 1UAPNNURqPAT1UN Occupancy Type
not more than five hundred doll..($500). 102 — PIERS
❑ I,as owner of On pmpeny.or my employees with wages As their sole compensation,
Will do the work.And the swclure is not intended or offered for sale(Sec.701,4,Business UFER
Add Proficubbv Code:The Contractor's License Law does not apply tu an owner of 104 - REBAR Required Inspections
property who builds of improves thereon,and who doessuch work himself or,h.ugh his
own employees.provided Nat such improvements Are not intended or offered for sale.If. 105 — ANCHOR BOLTS
however,the building or improvement is mid within one year of completion,the owner. lO6 — SEWER & WATER
builder will ban the burden of proving that he did not build lir improve for purpose of
sala.). 202 - UNDERFLOOR PLUMBING
01,as owner of the property,am exclusively contracting with licensed contmeton to 203 - UNDERFLOOR MECHANICAL
construct the project(Sec.70P,4,Business and Professions Code:)The Contractor's Li-
wine Law does not apply to an owner of property who Wilds or improves Oemon.and, 204 - UNDERFLOOR FRAME
who connotes for such prejecu with a conuacmrbs)ficeved Punuanto the Comncmra owe Law. 205 — UNDERFLOOR INSULATION
l em eacm tun Sec. B&PCfor srto n
p 301 - ROUGH PLUMBING
�`r 'SCOMPENSIf�—COMPENSATION DE rimQN� 302 - TUB & OR SHOWER
if 303 - ROUGH MECHANICAL
Ihercbyaffirmunder penalty of perjury one ofib uunwingdmlahationa: 304 — ROUGH ELECTRICAL
❑l have and will maintain a Centfcate of Consent to self-insure for Wohels Compen- 3OS — FRAME
cation,as provided for by Section 37M of dm Labor Code,for the performance of the
work for which be permit is issued. 306 — HOLDOWNS
❑I have and will maintain Workcer Compensation Insurance,in required by Section 3 07 - INSULATION
3700 of the Labor Code.for the performance of the work for which this Permit is issued.
My Worker's Compensation Insurance carrier end Policy number art: 308 - SHEETROCK
Carrier: Policy No.: 309 - EXTERIOR LATH
CERTIFICATECOMPENSATION INSURANCE ORKERS' 310 — INTERIOR LATH
maiasectionnand noikeompletedi(the permtlisfnronehundreddollunrISIgs) 311 - SCRATCH COAT
"rI`ss) 313 - ROOF NAIL
cc'
this in the pppppp���'torrrryryry ccofthewor forwhich s permit isissued,l shall not 501 - FINAL ELECTRICAL ENERGY
cmpinyany Pcrsnof her + yync.euli�+Jhe Werkcrs'Cnmperimum.
Laws of tiifnmia. a / 502 - FINAL PLUMBING ENERGY
Ap
N TOAPPLI NTeraCommakingNisCcninsofthe aborode,youhmuld 503 - FINAL MECHANICAL ENERGY
become h comp(to the Worker provisions
or thisPeron Permit
shai of theLaborcaked. must 504 - FINAL BUILDING ENERGY
OO forthwith comply with such provisions or this Permit shallMdpemed revoked.
CONSTRUCTION LENDING AGENCY 505 - FINAL ELECTRICAL
[—i .yi I hereby Off,,.Nat there is a construction lending agency for the Performance Of 506 - GAS TEST
C' > OcWork for Which box permiIisissued(See.3VJ7,Co,C.)
Lender's Nater. 507 - FINAL PLUMBING
f11
a z Lcnder'sAddress 508 - FINAL MECHANICAL
U O 1 certify that 1 have read Nis application and smm that the above information is 509 - FINAL GRADE
correct.I eprcc to comply with all city and county ordinances and smote laws relating Io
pU building construction,and hereby authonmrepresentatives ofhis city tochief Poll tire 5 FINAL PLANNING
above-mentioned m rl for inspection purposes.
IA P P y " PeeCity14 FIN LIC W RKS
L>r
liabilities,
save,indemnify And harmlessthe re Against
City
to inconsequ consequence
of the COWS And Of thispswhtch may in any way e¢mc against uid City
V 7 A APPLICANT
of the grantingRSTAN of this permit,
APPLICANT UN RSTAN SAND WILL COMPLY WI'f}ky,L NON POINT Issued by: Date
SOURCE RCG ION J
Re-roofs
nature of icanVComractor Data
HATARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle hamrdous material
v defined by IM1c Cupertino Municipal COJe.Chapter 9.12,and the Health and Safety
de.Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes u
Will the applicant or fm re building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection, 1 agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District/
Yea
Hit read dm hamNoua mamriala rtquirtmentsunJer Chapmr fi95 of Ne Calilnr
nia HCalth A Safely Coda,Sock.25505,25533 and 25530.1 understand thatifthe building
Iona not curremly ve a mnanl, itis my responsibility m notify the rccuPan,of the
requirement, must hem or toiaaaaneenfaCenificamN ey Signature of Applicant Date
owner or au rlmda em am All roof coverings to be Class"B" or better