02010088 cJBUI G DN
reRONo
DI PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
19866 MERRITT DR 02010088
OWNER'S NAME: APPLICATION SU DATE
LESINSKI JOHN S AND ELEANOR 01/22/2002
PHONE: SANITARY NO. CONTROL.NO.
I
c z ARCHITECT/ENGINEER: BUILDING PERM11INFO
w r� BLDG ELECT PLUMB MECH
g i LL IJ I L _J I---I
LICENSED CONTRACTOR'S DECLARATION
5 ? Job Description
z= 1 hereby nf)of that I nm licensed under provisions of Chapter 9 uommenei se
sic is in fScitulliorceanloect. mn3nrm<unsm<ssnneProf<..innsenae.nnamrr«n.e BATHROOM REMODEL
�yg- Limemllflm, ellen. �R�
,4 z Q Littnse Class Lic.N e* ,A L,E 93
o a U Dam Cnmramor
3 q.toARCHITECT'S DECLARATION
O 4 1 understood My
plms shall the used as public records
NOV^„T 7 y A`t Lqo oZ
r
I i o O Lic<m<d Pmressinml
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the BUILDING $
C Z< followinIs
g assort ec,Ian 7031.5.Bnafe
ncea and Pmmmrs Code:Any city ounty
r co4 5 0 0
E x O which requires a permit to construct.Bite,impar¢,demolish,or repair any structure
a3� prior to its issumxme also requites the applicant for such permit to file a signed%arm=., --- -- --- - ------ ---- — --- -
'hatheislicchs pursuant to the provisions of the Conuaaor's License law lChapter9 ee(Y ppffnn�I �,,tr� i'1 Valuation
(rommcncing with Sectimi 700 of Division 3 uT In.Business and Pmmo,inns Code) i Y t 3Y'D,�`3'J tYQ�'L:V•lY:u ''„
or that be is eaempt tmaefromand the basis for the alleged exemption.Any violation
of Section 7031.5 by any app wrma for o perat objects be applicant to a civil penalty
of not more than eve hundred molars C1500a 106PN NPEAM1DATION Occupancy Type
I,as owner of the property,or my employees with wages as dair sole compensation, 102 - PIERS
do he work,and the"smuclare isnot intended or offered fur sale(Sec.70 , _
'Business and Protessirm Code:The Contractor's License Law does not apply to an 103 - UFER Required Inspections
„tuner of papery Who builds or improves thereon,and who does such work himself 104 - REBAR
or through his own employees.provided that such improvements are not intended or
'.offfred for sale.If.nw,iFw.the Wildingo-m - men,I,soldwithin one - f --- - - - -" -_. '"
eb p^'°e °ldo 105 - ANCHOR BOliTS
completion,the,pose of sale.),
will have rite burden of proving that he did not build or
improve for purpose orsalo.). 106 - SEWER & WATER
..°1;ea owner of the propenY,ore axclmrely contracting with licensed rotractors to 2 02- - � ,i �•I - "- ---"
construct the project(See.7oaa.Busm<ss and Prefers mns code:)The Contractor. 2 03 - UNDERFLOOR MECHANICAL -
License Law does not apply to an owner of property who builds or improves thereon,
and.wba.comracts for such projects with a commcaas)licensed purruant.m he. -- -._.__.._.. -2 04 - —UNDERFLOOR'-FRAME'
Contractors License Law. ._. __. ... _...__ .... ..__,.
°Iamexemm nacr a&PCrm It 205 - UNDERFLOOR—INSULATION
Owner ( Dale /' 02 oZ 301 - ROUGH PLUMBING
OR' ;NPENSATIONDECLARATION 11 302 - TUB F< OR SHOWER
I herebyafGrm under penalty,of pcdurYoneof the following declarations: 303 - ROUGH MECHANICAL
° 1 have and will maintain a Certificate of Coascm to sat-insure for Workers 3 04 - ROUGH ELECTRICAL
Compen.eatian, as provided lot by Section 37M of the Labor Cade. for the
_ 'p<rrormante or me work Tor which rots permit is issaea. 3 05 - FRAME
°1 have and will maintain workers Compensation Insurance,as required by section 306 - HOEDOWNS
37W of the Lalw,code.for the performance of the work for which this pxrmh is 3 0 7 - INSULATION
issued My Worker Compc io Insurance c a -d Policy a ber,are:
308.:-r:SHEETROCK
Care CCRTIFICATIONOFEXEMPicPTIONFFROM WORKIS I -309` t�,',EXTBRIOR`•LATH
r.
Is.action rice)n ON INSURANCE
COMPENSATION _..._..._ 310-.:;:INTER'IOR—liATH— - — -tic'r•'a.:.' . \L_...__._ . ...
(Tri of tree completed Perrot 'r hundred ao SCRATCH COAT
ISIW)o less) _
'I n ry that,..n pert n e of work'for n E remit'. .a<a'1 313- - -ROOF -NAI•L•.�
shall a.,employ any peran in any mann,,so ns to become subject a me Workers 501 - FINAL ELECTRI CAL''�ENERGYmm
Compensation jou Laws oPCOhfomm.Dae '- . . . 502....-,. FINAL."PLUMBING ENERGY_...__.... _.._
Applicant .. _
NOT ICE TO APPLICANf..If,after making this Certificate or Exemption.you should 503 - FINAL MECHANICAL"ENERGY
become subject o the Workers Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall x deemed revoked. 5 0 4_ - . F.I NAL BUILDING -ENERGY, ," "z 11 .
_ . ..
CONSTRUCTION LENDING AGENCY ' . ' 505 - FINAL ELECTRICAL
I hereby M.that tire is conmuction lending agency for Nepe,arromica,
pc . Isnsucatsc3007Cis.C.) 506 - GAS TEST
, a - _
o p 'Lena`` " "" -507 - FINAL PLUMBING
Leader sAddress
- -
V'O I rrfyflan Ihave read hisapphcnf dmatetnatm noformation's 508 - FINAL MECHANICAL
(z cornu,1 agree to comply with all aut and authorize representatives
dna sate laws elating 509 - FINAL GRADE
O U to building icinnrnedpriand imyfori pectipurpose,.
uposehtmivesofMiscitymen¢,upon 510 - FINAL PLANNING
.the olio 1 eJ,propenyf inspection p s..
H y pVq ng t save damnify a d ke p hvmless ttie City of Cuperrno against
WliabiTt judgments,crsi a x which r any way against said
514 - FINAL PU IC WORKS
C.7-Z Ci,y ort ogee Ili granting of this pc t
AyPPL/,a-;g:�/T - ST ND WILL COMSLYW'ITH ALL N X-POIMMMGGG Issued by:
( Date
X UCs.Ga TION$.. _ /� 2 /2
re�rnrphcnnvco a« me/.,•, Re-roofs
RDOUS MATERIALS DISCLOSURE '
., W II tit ppl cant f,re building occupant store or handle hazardous material Type.of Roof
as def ed by the Cupertino Mimicipal Code.Ch Pt r 9 13 and the Health and Safety
Code Section,25532(0)' - •. n it I
°Y "r• ' r. 4 - ' . .
• a: .t�; :�40 :,, .f,T Ig.
. .;.. -A1Lroofs shall be inspected.prior-to.any_roofing.material,bei ng installed....._.. .._
,.
Will the applicant erfuture building occupant use equipment ordevicits which If a roof is installed'without first obtaining aninspectioniIlagree'to' remove
emit hamnidous air conmminana as defined by the Bay Area Air Quality Management
District' - all new materials for inspection. Applicant understands and will comply with _
all non-point source regulations-
h..f "t I have mad the hazardous materials requirements urdcr Chapt 695 of the
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that
if Ne building dues not cnOYhaveamnOnLthatit is my mponsibilitymnotifY the
decupant o reqs encs w'h must h ren prior to issuance of i Cenifiiste of
OcNpa j - _
Signature of Applicant - Date
All roof coverings to be Class•B
"or better
out prized agent
—'.' . ._ - .. .. . . -OFFICE .. _