02040133 (4) CITY OF CUPERTINO
BU.t.mrvc nrvtstoN PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10703 PEBBLE PL PHILIP VAN POETSCH 02040133
W NER-S NAME'. APPLICATION SUB DATE
i PHILIP VAN POETSCH 04/24/2002
PHONE: SANITARY NO. CONTROL NO.
O'1 O O ARCHITECD'ENGINEER: BUILDING PERMIT INFO
w— BLDG ELECT PLUMB MECH
LICENSED CONTRACFOR'S DECLARATION
eI hereby affirm that 1 am hccnsed under provisions of Chapter 9(commencing Job Description
:,4Fun with Section 7000)of Division 3 o(the Business and Professions Code.and my license KITCHEN REMODEL
Is in full forte and effect.
i z 6 License Clan Dog
o c.O Dae Common, F:'fp�fpa1e
I 3 u.F- ARCHITECT DECLARATION e�A L E
NSO S I understand my plans shall be use!as public records
p 0 Licensed Profession.) JUL 2 3 2002
OWNER-BUILDER DECLARATION
u a I hereby nff that 1 am exempt from the Crntmnmk License Law for the
C 3 afollowing reason.(Section 7031.5.Business and Professions Cale:Any city or county O O 0
Y�o which requires a permit to construct,alter,improve,demolish,or repair any smtnure
i3� Met to its «.also requires the applicant forsuch armtto file a signed statement
that he us,firearcil pursuant to the provisions of the Connectors license Less(Chapter 9 s .[ tpgr, rea„ Valuation
(commencing with Section 7000) f D vision 3 of the Business and Professions Code) '3 L®4F �4.'/..V V'
or that he is excmpi thiiefrom artistic basis for the alleged esemptron.Any vmlamn
-rf Section403 L5 by any applicant for a permit subjects the applicant m a civil penaltY-
,ifnot to ce man five norma!dollars(s5Bo1' 101 A N �AT I ON - Occupancy Type
❑1,as owner of the property,or my employees with wages as their sale compensation.
will do the work.and the strvnure isnotintended or offered for sale(See.7044,
Business and Professions Code:The Contractor s License Law does not apply men 103 - UFER Required Inspections' ' '1
Owner r of property Who Wilds or improvm thereon,and who does such work himself
or through his own employees.provided that such improvements an,not intended or 104 - REBAR
Offered for If;hi,wcvcc the budding �-- tis soldwithin otic-car of �- � � � - --��-�--�� � '�' '-----
completion,the owner-builder will have theburdernofproving that bedid not buildor 105 - ANCHOR BOLTS
impure for purpose of sari). 106 - SEWER & WATER
eCo. roatiep,upeuy, lusivelyconGdctigwimrcensedEnnt:actorsin 202 - UNDERFLOOR PLUMBING — --.:
conswa the Portico,(Sc70W,Business an!Professions Code:)The Contractor's .
License Law does nor apply to an owner of proPcny who bu ids or improves themon, 203 - UNDERFLOOR MECHANICAL: '
_and who contracts for such projects with a c°mm nous)licensed.pursuant.d.dhe
Contractors License Low., . .
—20'4 = UNDERFLOOR"
FRAME_
- - olam 7P unfit SS�. B&PCfar Wsrecon 205 - UNDERFLOORS INSULATION
ow°` —"'""1 .+rENsnnoN DECLARATIONp2 301 — ROUGH PLUMBING
Inerts rrrmanaer h or fire pernM1eronowm eeematmms: 302 - TUB & OR SHOWER
hereby Kou r Perjury g 303 - ROUGH MECHANICAL
❑ I have and will maintain a cemficam of Consent to self-insure for Warkers 304 - ROUGH ELECTRICAL
crmpeax.irn, as provided for by Section nor of the Labor Code. for the
performance af,ha wort.for which his Pamir is issued. 305 — FRAME
`�- ❑1 have and will earned.Worker's Compensation Insurance,as requited by Section 306 - HOLDOWNS
3700 of the Labor Code,for the parnmeance Of the work for which this permit is
].
issued.MrWorker's Compensation Insurance carrier amaPminymambcram: 307 - INSULATION
- ..
308_.= SHEETROCK. .;- " . . .
c:m e t "' Pritcy No.. < ;'t t K t iNil
CFRTIFICATOONOFE%ION INS FROM WORKERS'1 3O9 ' - EXTERIOR 'LATH •
COMPENSATION INSURANCE'` ''' __
- (ThisseeeonneednotbecompletedinnePermitisforonehundreddollars 310 --:';'INTERIORliATH.
(EIW)nr less) 311 - SCRATCH COAT
cmfr than in
" -' ROOF NAIL---.. A.. . _ ..
'shell t mpI.y any K s ny manner °as m become sub)en to he Workers' 501 - FINAL ELECTRICAL ENERGY
Con-,nm,on Laws of Cahf m a.Dare '
Applicant 502- - -F-INAL - PLUMBING ENERGY -
NOTICE TO APPLICANT:If,after making this Cenificase of Exemption,you should
become subject to he Worker's Compensation provisions of Labor coda.you most 503 - FINAL MECHANICAL ENERGY
CC fOi;1,wihcomply wihsuchprovisions Othis pero tsnaubaSeemedre�okad. ...504 FINAL BUILDING..-ENERGY
'consrRucrloly LENDING 505 — FINAL ELECTRICAL
Ft .., lendingce -
W ,�, 'ohne warx rprwman tats Perron is isscea esea.3on,cia.c.) _
506. - GAS TEST, --
z
1 hereby firm that there n a crnsm¢upn gen y pe
a agency for N<
... ,-Orman. _ - - ... ..._..-_ ._. ..___ _. -..._
y-p LeadersAame" 507 - FINAL PLUMBING
Lenleri Address
U O 1canirythat I banereadthinapprcadan and ante hat the inave infammailaon 508 — FINAL MECHANICAL
lis-E. e6riao.1 agree to comply with all city and county ordinances and state laws relating 509 - FINAL GRADE
U mbuWre-cocooned piquant,
for authorize eaprescntatives Of this it,,to enter upon
meaba.e-menrO«apropenyrmnspnrogpappses. - 510 - FINAL PLANNING
F. C. (We)ugreem save(indemnify and keep harmless the City of Cupcnino against
W liabilities,judgments.costs and expenses which may to any way action against said 514 - FINAL PUB I C WORKS
U Z City in I...a en«of the granting Of f'11is pe it. -
API'EIG. ❑` k 'ANDD NI Vl - IMPLY WITH ALL h)ON-PO NT Issued by: Date
.n SOUItC t TI, d�
Si,iaprf of AppicanVComncm - Done Re-roofs /
HA'LARDOUS MATERIALS DISCLOSURE
Will the ppiica t bare Wilding Occupant t handle haurdom material Type of Roofas defined by the Cu,,ardro Municipal C e Cbapt r 91 12,and the Health and Safety
Code,Section 25532(x) ]" f v t ;/`
❑vas - - _ 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, Pagree'to remove
emit ha edous air,ortuminam,as Jefny.tiy the Bry Alien An Quality Management
Dnnien ' / all new materials for inspection. Applicant understands and.will comply with
Dues u all non-point source regulations;
C. 1 have res!the hadadau:m,i viols rcquircmcntr do 5 Chapter b ,.rid the
fifth, uil Hadh s Sefny Code:Swoons 75505,25533 and 25534.1 understand hat
'ifthe building J«snotmrrcatlyly eat m:that n is my rtsprnsibilitY to notify be - - -
re emcnts wl ust t r t°ismonce of a Cendicae of
rad pmc � ,� 1.
_ Signature of Applicant Date _
r owner o,aagmd,.re agent Dila All roof coverings to be Class "B" or better
- - ... OFFICE .- _