02010029 (2) BUILDING DIVISION v PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10927 NORTHRIDGE SQ 02010029
OWNER'S NAME: APPLICATION SUB DATE
RANDOLPH RICHARD A AND ELIZAB 01/07/2002
PHONE: SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
w BLDGLE PLUM EC
�<a u —
a�yb LICIM1erebyafirmEhe IDam licensed undcR'pS DEionsof CM1�p er9(commencing Job Description
r° with Section 70W)of Division 3 of the Business and Prifirnions Care,and my license KITCHEN UPGRADE
zm I is in full force and effect.
C C 6 License Class Lip,p
K o a U Data Contractor
wa 00 .S—i ARCHITECT'S DECLARATION
F � I understand my plans shall be used as public records
r
aIn Licensed Professional /
X OWNER BUILDER DECLARATION
1 hereby affirm that Dam exempt from the Contractor's License Law for the,
F'i a followingreason.a. (anti to c nL5.Buaner, and Professions Code:Any city stcounty
O which requires a permit ro conswct,alcor,improve,demolish,or repay any structure $50
ace
a3oO •prior to its Vommce,also requires the applicant for such permit m rile a signed statement - -
that he is licensed p rommnuo thepro isions of the Contractors License Law(Chapter 9 _
(commencing with Scniom]000)of Division l of the Business and.Professions Code) ! +II�� ❑wlpor n�/`�,ea-, Valuation
or that he is exempt therefrom and the basis for the aIle ed exam tion.'An 31 O L 4.J'V U'
P g P Y violation
ofS«don 7031.5 by any applicabitfor a permit subjects the applicant to a civil pcnalry Ni.� �D�yn�P�r�
of not more than me hundred ddlars($500). 1014PN FOUNDATION - Occupancy Type
C 1,as owner of tic property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7094; 102
- -
Busmess'eHa Professions Code:The Contractors License Law does nor apply to an 103 — UFER Required Inspections
owner of property Who builds or improves thereon,and who does such work himself
or through his own employees.provided that such improvements arc not intended or .. 104. .—. REBAR
.offered for sale,If.However,the building or improvement is.sold wilhln'one yea of
completion,the owner-builder will have the burden of proving that he did not build or 105 — ANCHOR BOLTS
improve parposem".1c.). 106 - SEWER & WATER
Lasownerojecproperty.(Sen.7am excBusiness
Formationg ns
Caci ed Thaontranctor s 202 - UNDERFLOOR PLUMBING
ors t�
onsvuct the project Iappl to a.Busincss and Professions Code:)improves
ves Contractor i
and-whocommzatic Law esnotapplrtoanownwofpropmmand)licsori.pursuathinthe 203 — UNDERFLOOR MECHANICAL
and-who contracts far such projects with a<omraaor(s)licensed.pursuant io the
Contractors License Law. 204 - UNDERFLOOR' FRAME: _ .. . ._.
Cf am exem B& Cfonhls reason
owner � 67//pOZ-- 205 — UNDERFLOOR INSULATION
ORKER'5 COh NSATION D f hARAiION 301 — ROUGH PLUMBING
I hereby affirm under Penalty of perjury one of the following declarations: 302 — TUB & OR SHOWER
303 — ROUGH MECHANICAL
Compensation.1 have arta as provided a eby Sece or cons of m seLabor for Worker'sthe 3 04 - ROUGH ELECTRI CAL
rformaohe Provided for by genion 7700 of the Labor Code, for the —
performana of the work for which this pemtit is issued. 3 05 FRAME
C 1 have and will maintain Workers Compensation Insurance,as required by Section 3 06 - HOLDOWNS
PW of the labor Code,for the performance of the work for which this permit is
issued.My worked Compensation Insurance carrier and Policy number are: 307 - INSULATION
Carriei '' .r : : 'Policy No.:
SHEETROCK .
CERTIFICATION OF EXEMPTION FROM WORKERS',' t 309 — EXTERIOR LATH
_ COMPENSATION INSURANCE'
: ..........:. . .....
'fThis seetion need not Mcampincd if the permit is for one hundred dollars '3107*_ INTFRIOR- LiATH .
(Mamoness.) 311 — SCRATCH COAT
I certify the,in the performance of the work for which this permit is issued;13 13 - ROOF NAIL - -
shall not employ any person in any manner so as in become,subject to the Workers' S O 1 - FINAL ELECTRICAL ENERGY
Compensation Laws of Califm
omia.Da
App`'""` — 502 — FINAL -PLUMBING 'ENERGY
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
Z became.subjectmtheWorker'sCompensationprovisionsslimLaborCode,youmasf 503 - FINAL MECHANICAL ENERGY
Zforthwith comply with such provisions or this permit shall be deemed revoked.
504 — FINAL BUILDING ENERGY
h CONSTRUCTION LENDING AGENCY
a7Iherebyufhmuhatthereisaconxwctionlendingagencyfortheperformance 505 - FINAL ELECTRICAL
of the work for which this permit is issued(Sec 3097.Civ.C.I .506 GAS TEST
Lenders Name
Lender's Address Names- 507 - FINAL PLUMBING
v Q 1 certify that 1 have mad this application and state that he above information is 50 8 - FINAL MECHANICAL
Git Fy comet.1 agree m comply with all city and county ordinances and state laws relating 5 0 9 — FINAL GRADE
O r, to building construction,and hereby authorize representatives of this dry w enter upon
y the above-meotionedproperty for inspectionpuMo.es. 510 — FINAL PLANNIN
Fs 0. (We)agree msave.indemnify and keep hatmlcssthe City of Cupertino against
to liabilities,judgments,costs and expem.which may in any way came against said 514 - FINAL LI
V. Z Cl y c0 quence of the granting of this pe
' t••' Ar'LIC C1' c. NOSAND 'J_ r. ..IPL)WITH ALLNOV-P
P cul Issued by: Dale
1 si uturc 0 ApplicantlContractor „' Date Re-roofs '
HAZARDOUS MATER ALS DISCLOSURE
Will the applicant or town,building occupant sore or handle hazardous material Type of Roof .. . . ... _
as defined by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety _
Code,Scz imn 25532(x'.. '
❑res All roofs shall be inspected prior to any.roofing material,being.installed.
Wi 11 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
mit hazardous air contaminants as de tined by the Buy Arca Air Quality Management
'District' all new materials for inspection. Applicant understands and will comply with
•
[3 Yes
_1;e1c all non-point source regulations,
1 haveread the hazardous materials requirements under Chapter 6.95 of the
California Heulrh d,Safety Code,Sections 25505.25533 and 25539.1 understand that
ifthe Wingdm,wdcurcntlyhcvca tenant that' Izmy responsibility to notify the
ace av of the requi emems which rto issuance of a Certificate of
o up' Signature of Applicant Dale
nerwau tizedag!I Date All roof coverings to be Class"B" or better
-'- OFFICE