03090056 (2) CITY OF CUPERTINO
BUILDING mvlsloN PERMIT COQ TRAC��QR£INFO�LMA�I�'
BUILOmc ADDRESS: - ERIK KNEER PERMIT No.03090056
0 NER'SNAME: 10697 MORENGO DR PERMIT ISSUE DATE
IrSANITARY NO. CONTR
NE: OL NO,
ARCHITECfIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
:00 LICENSED CONTRACTOR'S DECLARATION Job DCSCrIpIIOn
2 F 1 herchy affirm that 1 am lirnnsed under provisions of Chapter 9(commencing
with Sccion]IXgl)of Division 3 of the Business and Professions Code,and my license is
+�d L ParLicense Class
ass k
aadd erfe"
j�_ in DEMO IN GROUND POOL
Lic
3�wDom Contractor
pp ARCHITECPS DECLARATION
of< 1 understand my plans,hall he cud as public records
ayU
°aLiecnud Professional
g OWNER BUILDER DECLARATION
i s 0 I hereby offvn the 11. exempt from the Contractor's :Any c Law for the
O O following mass..(S.I,i ](UI.S,Rosiness and Professions Cndc:Any city m county
-k E which requires.pemso re tires the
alae improve,demolish,or e a sig any saucmre
tai j, that
the incensed rmrequirce thovisiosofcant for such Contrarminricense Low(ned Chapter
-mm< thamenconir,witpSectiouwheprpoid.n31eCodiona 'sadProfsew(Chapmr9 Sq.Ft. Floor Area Valuation
,F� that he is exempth Section and the
basis f r the
the alleged
ess a prion.Any vi Coudo)tion or
or
��� Nm he is exempt themfrom and the basis for the alleged exemption.Any violation of 37534QI7 , Qn _
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of APN Number Occupancy Type
not more than five hundred dollars($500).
❑1,as owner of the property,or my employees with wages as their sale compensation,
will do the work.and the struma is not intended or offered for sale(Sec.7064,Business 704 - DEMO
and Professions Cade:The Contractor's License Law does not apply to an owner of Required Inspections
property who builds or improves to reomand who does such workliimself or through his
own employees,provided that such improvements are not intended or offered for sale.IL
however,the building or improvement is sold within one year of completion,the owner
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of to property,am exclusively contracting with licensed convectors to
construct the project(Sec.7144,Business and Professions Code:)The Contractor's Li.
conam Taw docs not apply to u owner of trouper(who builds of improves themon,end
who contracts Lawdo farsuchply to a withecof property licensed Wilds
pursuantto the Comractand
x em
Lew.
i am exptunder Se5-, B&P C for his..on
ate
WO R'S'C ENSATION DEC ION
I hereby affirm under penalty of perjury one.f f lowing declarations:
1 have and will maintain a Certificate of Consent to act Noodle for WorkersCumpcn-
Indion,az provided for by Section 37W of the Labor Cade,far to performance of the
work for which this permit is issued
1 have and will maintain Workers Compensation Insurance,az required by Section
37W of the Labor Care.for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number arc:
Cartier: Policy No.:
CERTIFICATE OF EXEM Pr10N FROM WORKERS'
COMPENSATION INSURANCE
(This accord need not M completed if the Permit is for one hundred dollars($1 00)
or Irm)
• 1 certify that in the performance of the work for which this permit is issued,1 shell not
employ any Person in any manner so as to become subject to the Workers Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Ccdifcate of Exemption,you should
become subject to the Worker's Compensation previsions orbit Labor Code,you must
.JO forthwith comply with such provisions ad this Permit shall he doomed invoked.
zCONSTRUC ION LENDING AGENCY
[-. 1 hereby affirm that there is a conswcion lending agency for the performance of
r17 the work for which this perm it is ismed(Sm.309],Co.C.)
QLenders Name
Under's Address
U Q 1 codify that I have read this application and sum that the above information is
V. F correct.1 agree to comply with all city and county ordinances and state laws relating to
O V building construction,and hereby atdhorim representatives of this city to enter upon the
�iPA shove-(Weiarm I.save forinspectionpurposes.
,1 G (We)agrcc tr save,indemnify and keep harmless the City of Cupertino against
N liabilities,judgment,casts and expenses which may in any way accrue against said City
U Z in consequence or the granting of this permit.
^' APPLICANT UNDERSTANDS_A.NUM.ILL COMPLY WITH AL NOW DINT Issued by: Date qlvl>
SOURCE REGULATIONS `` i -
-roofs
Dow
nature of App' aVLan scot Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle havarbas meatier
az defined by the Cupertino Municipal,Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
C]yes Roo
Will the applicant or future building occupant use equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
mit humorous it omeorinams as defncd by the Bay Arca Air out ity Management all new materials for inspection.
District?
ED yes 10h,
I have mail the Amadous materials requircm cos under Chapter 6.95 of the Califon
nia Health a Safety Code,Setters 25505.25533 and 25534.1 understand that if the building
data not can otly have a meant that it is my responsibility to mdfy a occupant of the
bem
minimum hichmusc. 'rrty' eoccofaCcrdficateofpc pan Signature of Applicant Date
— All roof coverings to be Class"B" or better
Owner u3 hori,.ad t - Data
SEP 0 8 2003
Of EICE COPY
IA! ACCIADARE WITH TH':CITYI OI1
JC`'_ AND
Tlvr§dlA w Viand specifications MUST
Tk'i��Hca ,.�� ,
k r job at all times and it is urcd
Rarov6uU to ake any Changes or, alterations
• ow am without written permissionfrom
ft DuAding Oept, City of Cupertino.
Tha §tampon of this plan and specifica600111
app of the vacation o an
r an t w tlydinance or tate law.
�Pi s
6ITY OF CUPERTINO
DEMO
CUPERTINO PERMIT APPLICATION FORM
• APN# 3 ��_ 3 41 _ O ` ^ Date: ^ 0 3
Building Address:
o o /`
Owner's Name: P one#:
Contractor: License#:
AZq387OZ
Contact: Phone#:
Applicant/ ontracttor:
Build n Permit Info:
BldgElect Plumb M
Job escription: a
-Residential: ommercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation:
Type of Construction: Occupancy Gr p:
• �✓vl o
Qt if
A is ble Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
BSEISMICRE Seismic Residential BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG