01100129 (2) CI BUDPN PERN
DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
10150 PHAR LAP DR 01100129
OWNER'S NAME APPLIC)TION S B DATE
JOHN & MARY KOEPPEN 10/24/2001
PHONE: SANITARY NO. CONTROL NO,
O O ARCHITECTIENGINEER: BUILDING PERMIT INFO
m C D ECT P MB MECH .
yz� L I
LICENSED CONTRACTOR'S DECLARATION
ret' I hereb affirm that 1 am licensed under fCha I 9(commencingJob Description
Y Provisions o Chapter
with Section 7000)°rrnvision3nnheBusinessandProfessionxcme dmyIcense KITCHEN REMODEL.
in full farce and feel. 1t�� Bp��n� pp C 1��a
Szw License class Lica 2 !—Iltlli LED
O ale eanraewr
0 ARCHITECT'S DECLARA I N
iIi S I undersand my plmrs shrill be axed as public rccards MAR U 6 2002
So O Licensed Professional
off OWNER-BUILDER DECLARATION
y
I hereby affirm Thal I am exempt from the Convenor's License Law for the
a 3�o 'ma
following atmon.(Section Business and Professions Cade:Any cityor county
rcounty
B_U_._I._L_D__.W_._Q_O_O
which requires arearnit Icommn her,improve.demolish.orparr anytaroI re
pno
r to its'..issuance, requires the applicantfor such permit afile axgnedstain ant,
In
1 aspw N
!pursuant !i i ns of N C m fors License Law(Chapter 9 f .y S Valuation
(cam vg wrN Sm )Bull)of Divis o l f the Business iM Pr4feulonx Coder l���� 1-`3 �' V CYY���Jy .Ch j <4-
ar tM1m he is exanpi Ihdefrom mud the basis for the alleged eiemptirn.Any violation
of Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty
of Ammmeban five hundred dollars(s5u0). 101APNIP )AT ION "' "' Occupancy Type
❑1;as own,,of propert,or my employees with wages ax her,sale morpemsaian, 1 02 - PIERS
will do the work,and the awnurc is nm'ina coded o,offered dor sale(see.7(44,' 103 — UFER Required Inspections"' E
'Business and Profrssimas Cade:The Contractor's License Law does not apply w m '
owner of progeny Who Wilds or improves theater,and who does such work himself 104 - REBAR
or through his own employees,provided that such improvements are not intended or
offeied on sale.IL however,the building or improvement is sold within one year or 1 O S - ANCHOR BOLTS
completion,the owner Wilder will have the burden of proving that he did am Wild or -
improvofar pmpoeeafole.). 106 - SEWER & WATER '
.0i;asasmaorIne 'nr:omexclusively contracting with ReensedconGanonto 202 - -UNDERFLOOR PLUMBING
Liantrum the Project(Sm.7r3W.Business and Professions Code:)The Commnarx 2 03 - UNDERFLOOR MECHANICAL:;—
cense Law does not apply wan owner of proporty who W Ilds or improves thereon,
and.wno nndmdx.fnr amen project,with a eoneacm F)licemed pursuam w the. _ 2 04' ---UNDERFLOOR--'FRAME' -'-
Comnno`s License Lrw., ,
❑I am",mpl Aider soo � :R&P C fordinamon 205 - UNDERFLOOW I'NSUL'ATION
Owner r ' """' Date 301 - ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION 302 - TUB & OR SHOWER
I herebydirt,underpema1lyofperji,y ane ofthe following declarations:— 303 — ROUGH MECHANICAL
i( ❑ I ne4 and will maintain a Certificate of Consent m self-insure for Worker, 3 04 - ROUGH ELECTRICAL
Compensation.as;Provided far by section 37110 of the Labor Code, for the
perrormamoofine work for wbim lox ri-ran k i...ed. 3 05 - FRAME
❑I have and will mainiaid Worker's Compenotiion'Inxurmice,as rcquirtd by Section 3 0 6 - HOEDOWNS
_ 37Wof the Latin,Code;far the performance of the work far which In,, ,.it ix 3 07 - INSULATION
issue d.'My Worker's Comperisetion Insurance carrier and Polity numM are: _
308 = SHEETROCK
CemsS° Rh t.:!I[ stlt'-IkPal yNo: .• �'•-Lv. •r.,l ,•�.� _ - _ -xi'I rI .3 _.
II+' )
CERTIFICATION OF EXEMPTION FROM'.WORKCRISi fa'-k --1309 ' s,•^EXTERIOR-'LATH"•
COMPENSATION INSURANCE
" ---310'•� - •PNTERIOR--L-ATHr— - - _
(This oection'a,md`not ba completed if the permit is for one hundred dollars x:=
DIDB)arloss.) 1 . 311 SCRATCH COAT
- 313 - ROOF- NAIL-- -
d .
1 cenfy thatinth perpr of thework for thspermt ' ssued,I d"
,hall not a lay aa//��yper,onjn - '" io become nublcct m the Workers' 501 - FINAL EliECTRI CAli''•ENERGY
Com- lion��Lei�abl'CAWore nersoas-
NOTICETOAPPLTCAi4PilL�iek.'�g�i lmrgmo pr Ex�mpban.you mama 502 _ FINAL PLUMBING ENERGY _
csubjeluolhe Worker's Campensvtiun provisions ohne labor Code,you mus 503 FINAL MECHANICAL ENERGY
pa lac M c"ldy with such provisions or this permit shall be dttmW mvokcd.
0 504 - FINAL BUILDING ENERGY
y - `i' I":t"CONSTRUCTION LENDING AGENCY '" 505 - FINAL ELECTRICAL
I., 'I hemlry affirm man them is'a connmction lending agency foi the perfohnmice - ' -
ormeworkmrwmrnthisp<mlRI,ixsa.dcsm.3W7.•Cis C) ' 506 GAS TEST
.W... .Lender's Ndmc" .: i. c.. .. ::.. _ . ... . --. _ .
0 507 - FINAL PLUMBING. ,
a Lenders AddresR•',..:'., • , '.
U I�cen fy that 1 have head this application and sae tha dhe above information is 508 - FINAL MECHANICALIli "
tsdt:a cotrca.1 agree to comply with all,city and county ordinances and state laws relating 509 - FINAL GRADE
' O;, to Wildingeorstmvim and nerebyaatnorumisraseaativexothis city toenter upon 510 - FINAL PLAE51)ate
G
the above-mentioned property for inspection purposes.,, .
A. (We)agate to save. n ica nify and keep haran esi the City of Cupertino against 514 - FINAL PUBliabilities dgments.case and eMI whlch�mny in any wayaccroe.'gains saidU-z Cily In onscqucna of megramin of lhiR 4PPf ANT UNDERSTA.YD 'D VII MPLY WITHALL NON-PoI Issued b
CE REGULATIONS!' ''- P Y
g are ofApplica ,. J ZDV " Re-roofs C.
HAZARD6US MATERIALS DISCLOSURE '
WJIINe pplca I or'f auto Wldingac "a ha°dleb,l:wotlsmaenal Type of Roof
xs def rd by,the Cupen n M p 1 Codc CM1 pt r 9.12,and the Health and Safety
code ave:zss}x,741 pNo'' � v.
..All' ' i'i:'te-: .� .•�i..f^fy�, I^ ,_Y},:'o-.lea4Y: - v..., , ,0 .
.All roofs shall be iprior
,to_to any-roofing mater al being installed__ _
Will the uppliw I at future bilding«apant use equpment m devices which If a roof is installed-without first obtaining an inspection;-I'agiee to'�emove
emn hazardous as conlammamx es deEnN by the Bay Area Air Quality Management
District? '. , all new materials for inspection. Applicant understands and will comply with
v
❑ "° - '- all non-point source regulations'.. I ,
Lhivc read the Budd us materials mamma lox under Chapter 6.95 of the
Colifo" ealth&Safety Code,Soctions 25505.25533 and 25534.I understand that
ifthe ildin d note Idly have A mant.that it is my osponshfly 10 ratify be ,
ac i re hich must be rat poor to rss mace of a Certificate of
r °' plum Signature of Applicant Date
Owner or Arthritic go //.Data/Date All roof coverings to be Class"B"or better
s 1 . ... .. • ) OFFICE -. . .