02100172 (2) CITY of CUPERTINo ����,�
BUILDING DIVISION PERMIT CONTRACTORR INF , RMATT10 11 '
dazx ' . ,, , < 3r,
EH2)1N691t1+ESls1YANNISPORT DR CRW INDUSTRIES PERMITNO2100172
111 SON STEVEN J 1157 DELL AVE . APPLICATI)OS'tlEZkIffr2002
PHONE: 4O8 378-2477 SANITARY NO./ CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p00 LICENSED CON'RACfOR'S DECLARATION p
set F 1 herebyfO
arm,hat I am licensed under revisions of Chapter 9(commencingn
wish Sectinn7 MMll of Diviainnlnf the Bud send momasienscp and my licenseREMODEL BATHRMil SI� cQ
in full fnree a e of Z Art`
Asa_ LicemseGl 1 VVV r-1111 A.t—��
Z— Dale — - — Gnn
E2M AsshalTECI'SD I.licrec0N DEC 2 2002
,Eo�<< jland my plans shall be used as public records
LL0 I(.iid Professional
OWNER-BUILDER DECLARATION
Contractors
ON
0 C 1 Masa a13rm on 1 1. exempt from the fessions C's License Law for the BUILDING $B 5 0 0 0
�+t 600 Which sac uires..(Section 10315. L,ahcr, and ve demolish,
Choc:Any city at county
x$(vat whicM1 acquires a permit m enndmn,el¢r,improve,demolish.hr repair any structure
w—N pdurto its issuance,also myuires the applicant fersoch pe,mitto file a signed smmmem
that he is licensed pursuant o the pmvisinns of be Contractor's License Law(Chapter 9 3STI5fft4l0&k9A&0 Valuation
hoommenci ng with Section 7000)of Division 3 of the B usihms and Professions Code)or
�1 That he is exempt therefrom and be hash far in,alleged exemgion.Any violation of
Section 7031.5 by any epplicam far a permit subjects the applicant to a civil penalty of UAIDNN Occupancy Type
not mare than five hundred dmlara(s500). 102 - PIERS
I,as owner of the property,or my employees with wages as their sole eampcnsatinn,
will do the work,and the swctum is not intended or offered for sale(5x.7(544.Business
and Professions Code:The Canoacross License Law does hill apply man owner of 104 - REBAR Required Inspections
property who builds or burrows thereon,and who does such work himselfor through his
own employees.provided that such improvements are net intended or offered for sale.If, 105 — ANCHOR BOLTS
however.the building or improvement is sold Wilda one year of completion,the owner lO6 — SEWER & WATER
builder will haus the burden of proving that he did not Wild or improve for purpose of
rale) 202 - UNDERFLOOR PLUMBING
❑ I,as owner of the properly,am exclusively contracting with licensed contractors it) 203 — UNDERFLOOR MECHANICAL
construct the project(Sec.7014,Rusimss and Professions Codm)no Conlractore Li.
cense law does not apply m an owner ofpmperty who builds or improves lemon,and, 204 — UNDERFLOOR FRAME
who contmcufor such projects with a contractor(s)licensed pursuant o the Contractors
License Law. 205 - UNDERFLOOR INSULATION
❑ Ism exempt under Sec. ,a&P C for this roman 301 - ROUGH PLUMBING
4Vner Data 302 - TUB & OR SHOWER
WORKER'S COMPENSATIONDECLARATION 303 - ROUGH MECHANICAL
I herebyallirm under penally of perjury one of the following declarations: 304 — ROUGH ELECTRICAL
❑Ihave and will maintain a Cool Bcam of Consent to self-insure for worker's Compel 3O5 — FRAME
selion,m provided for by Section 3700 of the Labor Code,our the Performance of the
work for which this permit is issued. 3 06 — HOLDOWNS
❑1 hart and will maintain Worker's Compensation Insurance,as required by section 307 - INSULATION
37fl0of he Labor Coca,far the performance of thewa,k for hichmis permiti asocd.
My ,rkeesComNnsa/tio�nlnsuranceeameranJPobcy berare: 78 308 - SHEETROCK
}t
F er:5#fJ 4/i IQ a PaEer —� "/ � 8 309 — EXTERIOR LATH
CERTIFICATEOFEXEMI'1'IDNF OMWORKERS'
COMPENSATION INSURANCE 310 - INTERIOR LATH
(This section need not he uoundoled if the permit is Phone hundred dollarsDIM) 311 - SCRATCH COAT
lC9i.) 313 - ROOF NAIL
1 ccnify that in the pofformerme of the work for which this permit is issued,1shall not 501 - FINAL ELECTRICAL ENERGY
employ any portion in any manner an as m become subject o the Workers Compensation
Laws afcelifan ia.Date 502 - FINAL PLUMBING ENERGY
Applicant
NOTICE TO APPLICANT:ll;after making this Certificate of Exemption,you should 503 - FINAL MECHANICAL ENERGY
bcoome subject to the Worker:compensation provisions of the Labor Code,you muss 504 - FINAL BUILDING ENERGY
OO forthwith comply with such provisions or this permilsball he deemed revoked.
z CONSTRUCf10NLENDING AG1iNCY 505 - FINAL ELECTRICAL
I hermyalTrm mat mere iso cmaumnien lending agency In,the performanceof 506 - GAS TEST
y > the work for which this permitisissued(See 3097,ON.Q 507 - FINAL PLUMBING
W Q Lander',Name
G
Lond
e
r',
Add.. 508 - FINAL MECHANICAL
UO 1xneematIhaveroad oristyandcunand dalemsthe ndaboveimmrmMinmis 509 - FINAL GRADE A
W F correct.1 comfy
t comply with all city and county d date t at and state laws relating m (//��
building construction,and hereby Minutiae rcpmacmalives of lis city to enterupon the 5,1-Q\ FINAL PLANNING
shove-mentioned roe rt lar inspection purpose.
a pry p p p 5 4 - FIN IC W RKS
(Wo)agree m nave,indemnify and keep harmless the City or Cupertino against
N I.cou.q.cwe of th,ens¢end of his expenses which may in any way acerae against said City /�
V z Aconsequence NDERSTIingnf this per mit. L/
^ APPLICANT UNDERST AND WILL COMPLY WITH ALL ON-POINT Issued by: Date
SOURCE RF U ION .
9 � ou� tmw aZ Re-roofs
Sig pplw.H onRDO Dmc
HAZARDOUS MATERIALS
amomorhandl Type of Roof
Will the applicant or future i,odCo r,C1apm,9A or handle lhardnusd material
s JefineJ by the Cupertino Municipal Cudo,Chapter 4.12,and me Health and Safety
•An.ovCS 25532(.)'' tom,. - All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
omit Mandous aircumaminants do fined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes No
1 have mad me hurardoas mamrlalsmyuirements under Clmpmr 6.95 of the Califnr.
nits Ili,, &Sally Ctalc,&pions 255115,25533 and 25,5,14.1 undcrsmnJ malifthe huilJing
does 'ot currently h .¢nam,that it is my resrymeibBe ma
hy Idly the occupant of me
re mments whi mtbet prier ul issuance ofd CenifK:ac of0. aney Signature of Applicant Date
Owner authmn.d agent Date All roof coverings to be Class "B" or better
CITY OF CUPERTINO
auu.mNc mvtsloN PERMIT `CONTRACTOR INFORMATION
Bu Dl RE{q:YANNISPORT DR BOB GERE MASONRY PERMIT V2110072
DWANMRSON STEVEN J 480 CROSSLEES DR APPLICAIJCTJ 1 T)I`2002
Ah
orHONE: 408 972-1285 SANITARY NO. / CONTROL.NO.
ARCHITECTIENGINBER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
1400 LICENSED CONTRACTOR'S DECLARATION
m P I hereby affrm that I am licensed under Provisions of Chapter 9(commencing b Description
with3emhm 7glBbrfI)ivision 3 of the Bodnar nd Profemhrm ClWc,a dmylimeaeis REPLACE CHIMNE '
m Leith nJ —.ril
e.
0m� Datc + Co w
ARCHITECTS
K z IanJ my plans shall he used as public reenrds
6Cy
�Q Licensed Professional
OWNER BUILDER DECLARATION
t�i 1 hereby allirm that I am mompl lean the Conamors License Law for the $5995
M-2
fallowing Yemen.(Section 7031.5,Business and Professions Code:Any city or county
d which requires a genii m coma rml,cher,improve.demolish.or repair any stmetme
t—Zi prior to its issuance.also require the applicant for such permit in file a signed statement
pp < that he is licensed pursuant to Ne provisions I)(the CantmclnrsLicense Law(Chapter 9 3Se§FtIBIBIRA06 Valuation
y+�0 (commencing with Section 7")of Division 3 ofthe Busidom and Professions Code)or
my that he is exempt therefrom and thn basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant In a Civil Penalty of pN Occupancy Type
notmmcthan rwhundred douars($500). 312 - CHIMNEY . REBA & STRAPS
I,as owner of the property,or my employees with wages u their sole compensation,
will do dm wort,and the anet.is not intended moffered for sale(Sec.1MC,Business 514 Fiii-AT,
weRjEs
and R f aadons Code:The Comractora License Law does not apply to an owner of egwre Inspections
property who W ildsor improve Merton,and who dices such work bireself or through his
own employees,provided Nal such improvements are not intended or offered for sale.IL
however,the building or improvement is sold within one year of completion,the owner
milder will have the burden of proving That he did not Wild or improve for purpose of
salt.).
❑I,as owner of the property,am exclusively contracting wit licensed emanations to
construct the project(Sea 70k4,Beat..and Professions Cd R:)The Con mitou's Li.
man Law does not apply to an owner of progeny who Wilds or improve demon.and,
who contracts for such projects with a contractor(s)licensed pursuant to the Contracmr's
License Law.
❑ I am exempt under Sec. .B ds P C for this remnn
Owner Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declanuom:
❑1 hero and will maintain aCenificate of Coment to self-insure for Wmkeri Compere
satin,as provided for by Section 3701 of the Labor Code,for the performance of the
.,,it for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance,m required by Section
1700 of the Labor Code,for the performance of tW work for which this permit is issue,
My Woher's Comonst lnsurancscartic uPolieynumberme;
Cattle, ru/": WORKERS'b 7
CERTIFICATEOE%EMPI'1 MWORKERS'
COMPENSATION INSURANCE
(This section need not nccompleted if the permit is for one hundred dollars IS ILMB
east
I cenify that in the performance of the work for which this permit is issued.I shall not
employ any pown in any manner so e m become subject o the Workcri Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenilicam of Exemption,you should
become subject In the Worker's Compensation provisions of the Labor Code,you muss
OO forthwith comply with such provisions or this permit shall ire deemed mvrked.
z 14CONSTRUCTION LENDING AGENCY
[—i I hereby affirm that there is a construction lending agency for the performance of
C r7 the work for which this permit is issued(Sec.MIST.Civ,C.)
CQ Lenders Name
Z Lender's Address
(� Q 1 minify iml 1 have read this application and mate that the above information is
{kt f"' correct.l agree to comply with all city and county ordinances and state laws relating to
pU building contraction,and hetehy authodm mprcmnmtives of this city to enter upon the
above mentioned property for inspection purposes t
eH^ (We)agree to save.indemnify and keep mantle.the City of Cupertino against
y liabilities,judgments.costs and expenses which may in any way accrue against said City — I
Uin consequence of of the granting of this perm it,
z APPLICA ERS ANDS AND .L COMPLY WIT
AL NON- DINT Issued by: Date
SOURCE EGU
�� e-roofs
Signam of APPliceHAZAran Dam
HAZARD S ATE RIALS Dslum or U . Type Of ROOF
Will the applicant or future building rxc hupor,mm or handle haardoanmaterial
n defined by the Cupeninr umci al Cttle,Chapter,9.12,and the licalth and Safety
cnee,oyes N All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupant true equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
en if mmodous air cutworm rte efned by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes No
1 have read the IlaraN ms unwrials requirements under chapter 6,95 of the Cxlifur.
niallmlN&Safety Cade.Seciians25505,25533md25534,lunderstandthatifthe iMing
does out currently h ant Out it is my nsihillty m nmify the oecup I of
rcgwremen wni mn4 epriortq teateafa�ytp/tt SignatitreofApplicant Date
Owner or au nrisc agent /! Dare All roof coverings to be Class "B"or better