01090106 (2) CITY OF
PERTNO
BUILDING DONPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
20171 PACIFICA DR AMERICAN BRANDS CONSTRUC ION01090106
OWNER'S NAME: APPLICATION SIB)DATE
WOODBECK JANE V 1145 HAWKS HILL ROAD 09/24/2001
0-
PHONE: SANITARY NO. CONTROL NO.
po (408) 210-4945
O O ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLEG ELVT PLUMB MECH
5 ny 2 LICENSED CONTRACTOR'S DECLARATION Job Descrici
Z-C I hereby strum that 1 Am liocMed under provisions of Chapter 9(commencing
retu) widiSeaion]000)ofDivision3ofsheBusinessandProfessi...Cod. dmylbenu REPLACE PATIO ENCLOS E.
'3 is in full face end t. O-7
19 License C ss Lic,g
O a Data Contmn
i Q In shall
he DEC
y 1 undersnd my plans shall be Marius public records s�
<T<
7 O Licensed Pmfessiondl _
OWNER BUILDER DECLARATION
s'
Hot 1 hereby affirm(hot 1 em exempt fro n the Convector's License Law for the � _
C < following reason (Sat ]0nstr Businem and improve,
d aro demolish,
Cade:Any city or county 00
D
which rtquver a perms t construct,eller.Improve,demolish,m rtpev any swcmte
° 3� 'pnaloiulvauaax,sl req .tit apPbcanl rd such punriuo Bk augnvl nemmem - ._ 1 H Ir 1'
C drat he ld licensed puleuantmlhe provulons of Nc Conveno/s Laenu law(Cheper9
(commencing with Sectn7")ofoivmmd 3 ofine Business end Pryfenmm Cade) C �� .;3,6 0. , F sk: l,I's t j Valuation
or that he Is exempt therefrom and the bees for Ne alleged eAempliod.Any violation
cf Section]0313 by any applicant fora permit subjecu the applicant to a civil penalty y.am.�.w
afom
ot oa man five hunared d.11.(SN)B. 101AEN P•C7t.7fPYJAT I ON d Occupancy Type
❑I,es awns of da propcny.or my employees wire wages u Meir sok eompenatiam 102 - PIERS
win do the work.and the swnum is not intended or oRered for Asia(See ]044.
,Business
'and Professions Code:The Con 's License Law does not apply to an 103 - UFER Required Inspections'`•
owner of property Who builds or improves Merton,and who does such work himself 104 - REBAR _
or throu h his own employers.Provided that such improvements an,not intended M
"offered for sola If,howevm,the building m improvement is mid within ora year of 105 - ANCHOR BOLTS
icompletion,do mmun-I uilda will have the burden of paving that bedid am build ar
mprove for puryoseaf A.le.). 106 - SEWER & WATER '
_ _. .. ..__. -. - 202 - UNDERFLOOR PLUMBING
❑1,m owns of me propeny,am exclusively contracting with lkcosd cantructon m
cormtroat the prokci(See.Tau,Buainerx teed Pmfassmaa Cade:)The CantnciarS 203 - UNDERFLOOR MECHANICAL '
License Law does not apply to an owner of propeny who builds or impmvm thereon,
Add who.tm rrama for such projects with n conlandfa)licensed pureuant so dte 2 04 - UNDERFLOOR FRAME
Convect&,License law.
[31 AM exempt oder Sec. .B RPCfM thio rtnson 205 - UNDERFLOOR INSULATION
owner "' Data 301 - ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION 302 - TUB & OR SHOWER
I hereby afhm under panaty,of perjury one of the following dalamtiens: 303 _ ROUGH MECHANICAL
❑ 1 have and will mCe
amt.i.. nircate of Consent 1a selr na re for W~, 304 ROUGH ELECTRICAL •
Compensation, as provided for by Section 37W of the Lebo, Code, for me
_ pedomtana of ma work for which this permit is Issued., . 305 — FRAME
Nhave and will maintain Worker's Compensation Insurance,u required by Section 306 - HOLDOWNS
of the Labor Code.for the performance a the work fee which Nie permit is 3 0 7 - INSULATION
issued.My Workees Compensation Insurance carrier and Policy number are:
�PliryNo.: 308" SHEE ROCK
C'1_ cERATONOFEXEMPTIONFROM WORKERS . a - 09 '= EXTERIOR' LATH', ,
,., COMPENSATION INSURANCE. ..
310 -.- " INTERIOR LATH; 7_._......._._ .
(Ohn senior lied lid W completed if the Permit is for ooe hundred dollen 311 - SCRATCH COAT
(SI00)or IessJ
I cmify than in the,Perf...u¢6f the which this permit is issued,) 313 —'ROOF NAIL
shill nil employ any person in any manner so as to become subject to the Workers' 501 - FINAL ELECTRI CAL`ENERGY
ComApplpensation Laws arcalromla.Date 502 - FINAL PLUMBING ENERGY
NOTICnt
NOTICE TO APPLICANT.IL aRa making this Certificate of Exemption,you should
Z baawithconpththsuchprvompcneathisprmitsnsofthdLabmCvoked. east 503 - FINAL MECHANICAL ENERGY
OO forthwith comply withnuNSTR proor visions DINnAGEhall bedeemedrevoked. 504 - FINAL BUILDING ENERGY,
GF,r.v� chatten:I,i ms"ed LENDING AGENCY 505 - FINAL ELECTRICAL
s I hereby aRml this mere is a conswnic. lending v.C.ry forme perfmmsrue
ter „ of ilte wink for which this permit is issued(Sec.309],Civ.CJ 506 - GAS TEST
W'q
Uncles Name
- 507 - FINAL PLUMBING.
Lender's Address
N�.r I ccnify that I have reed Nis application ed nate that the above informMinn is 508 - FINAL MECHANI CAL
Las t'r cone .I agree to comply with ell city and county ordinences and sate laws reining 509 - FINAL GRADE
�'f,J to building mnsmuctinn,and hereby Ambrose representatives of this city to enter upon
W the above-mentioned propeny for impatian purposes.. 510 — FINAL PLANNING
}.r pe (We)agree to save,indemnify end kap harrdess the City of Cupertino against
U vJ Iihy'!li`A,judgmans,cost'ran axpensn whish may in any way eccme against Aerie 514 - FINAL UB C WORKS
U'En City i' onagoence of the an gof thiopmmit.
SPP. .ANT UIYD SN AND WILL WITH ALL�O,IPOJN,t Issued by: Date
E,p�9 99'�!// �/�
atdgor t minor, - Dna Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fume boldin acupom store m handle hnndous matdd Type of Roof - -- - --•
es def ed by the Cupenl..Man= Is,Chapter 9.13 and the Health and Safety
Code Semion.355J21a)7 r I s I i `r .'i '''r. 1
❑Yes' l o Y.:�u All roofs shall be inspectedprior to any roofing-material being installed.
Will the Applicant M furore buil Accupern use equipment or devices which If a roof is installed without first obtaining an inspection;I agree to remove
• emit herardous air contaminants as d ned by the Bay Arca Air Quality Management r
District? all new materials for inspection. Applicant understands and will comply with
rl. DyC. No all non-point source regulations. •
I have,sad the hazardous materials re,Mremenu under Chapter 6.95 of the
Celifomia Health&Safety Code dons 35305,35533 end 35534.1 understand dear
if,he building does not cu euenanl than it is my responsibility to notify the
Mc, of the rest iinm s 4 ch must he mel prior to issuance of a Cenife a of
5 ° P " Signature of Applicant Date
�— Data 9 All roof coverings to be Class "Brr or better
OFFICE