01100083 (2) TY OF
cl
BUILDING mySI
SIONPERMIrI' CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
OWNER'S NAME: APPLICATION SUB DATE
VANDER KOOI MARVIN K AND JUDI 10/11/2001
PHONE: SANITARY NO. CONTROL NO.
❑O O ARCHITECT/ENGINEER: - BUILDING PERMIT INFO
w- BLDG ELECT PLUMB MECH
a
•Sb LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby alarm that I em licesW utd
er provisions of Chapter 9lcnencing P
iy'2 tu❑i wit Section 9008 of Divis'on 3 of the Business and Professions Code,and my license
;xa5 iaimm�romeanappct 3Z. KITCHEN REMODEL.
.r<w b uttnx las a
i 3. Doc / o Corona
•'=o I un esiand m�rl�onv sM1slll be�sea E puMi<reco0ras /
r g ��! 0
Lianxd Profnsiond
'S r OWNER-BUILDER DECLARATION
u� y I hereby.(Brio that 11. exempt sfies.
an to Conions Ccs :Any C law for the
Z following mason menti t 9031.5.Business and ice,de o demolish.
C"de:Any can structure
FF❑ which requires a pewit m construct,alter improve,dcmolisM1,or repair any swnum $2QQQO
63$ ..puonoiu tensed ,also rtquimrthe npplicamt«w<hpennitmfileerignedwsours) -- -- - -- - ------ -- - - - - ------ -- - ---------.____ ________
that he is littered puisuinuo to Prbvistbm oftM ConwnWs Li«rate law(Chapa9 S Ft. Flo rAreat , r, Valuation
(cammceing wits Srction 9000)Pf Division Sof the eusieu ptbt fewios Cads) f'{}3;'J'-3, q` 12 o, aa?gI !L �{)`� ;
mnhot he is exempt meiefrom�and the basis f«the alldgcd eiemµib�.any womr;pn 3.57010 7 3'."0 0-
of«m¢DthanSlb hunted dollan($500) blep6meaPplmmtt°.ctvnxnehy APN Number 1 1 - •" Occupancy Type
❑Las owner of to ro r, employees th write,as their,sole mm tion, 101 - FOUNDATION
P P Y«myt p Yeuwipenes
will do the work,and the nnmurt is not intended e eofferedLaw for salt apply to an - t
'Business enol Pry Whom Wilds
Code:The rovesContractor'sthento Licenx law does not apply m am 10 3 - UFER Required Inspections' `
owner of Progeny Who Wiles or improves t such improvements
who does such work himself
or trust It his own employees,provided But such iernent issou.rt not intended
year or 104 -- REBAR I+
,o@rM for ale.IL however.me building w improvcnrcnt is sold within one Ycar or _� �
completion,the owner-Wilder will have the burden ofproving that he did not build or 105 - ANCHOR BOLTS '• "ll•OL '�•
improve for Purpose of sale.).
106 - .SEWER & .WATER ..__..._. _..----- - .--' --_. --- _. ._
construct
on sowher ofthe propcnYam<xusiness acmuacd"pwi Codenxdemuacaonm
conawn the prosect(s«. to a,Busies.and ery who coao:)iThemproves Contractor',a 2O2 - UNDERFLOOR PLUMBING ,I
License law does nmapply roan ojower of progeny wno bmicese impmvcsttrcon' 203 - UNDERFLOOR MECHANICAL
e ._ ..and who eomraens f«such projects wit e.rovumogsl licensed pursuant to rot_ _ _ _..... .. .... .. . . ._.. _ . .
01 arrora License law... 204 ' - UNDERFLOOR . FRAME; ,,.
❑lam exempt under Sec." ` B&PCf«tis reason 205 - UNDERFLOOR t INSUfATION
Owner'' wORKER'pCOMPDate ON DECLARATION 301 - ROUGH PLUMBING
�'• Ihereby arrmtunder PSwRyofperjury one of,tpfollowing declarations: 302 - TUB & OR SHOWER
❑ 1 have and will mainnm b Cer ieaate'of content to alr-iromp for Worms 303 - ROUGH MECHANICAL
Compensation, a;provided for by Section 37W of to Labor Code, far me 304 — ROUGH ELECTRICAL
fow
perarea of me w«k for which tis pannus is issuad.
305 - FRAME
OI hove.W will niabuitin,Worker.Coinpenatiun Insurance,as required by Section 306 - HOEDOWNS
'-- 3900'uf the Labor Code,for to performance of the work for which this pewit is
isivcd.My WortN`Compen ton Insurer a cerise mrd Policy numbir em: . . 307---.. __ _ _INSULATION . _.... __.
..__
olcyNn.• '3�F�'697--77 t308 SHEETROCK,• a hl 1,
ft CERTIFICATIONOF-EXEMFI'IONFR MFR MWORRKERS' r - ' f "• s• 'sJ f { ''k' '
d 309 - EXTERIOR_LATH
"- `rti• ,-'•.tion nk,nob mpinoN, pcwvCi'. one. . _ .. .-_'_'"_ _ _ _._.__ _ _.....__..__._._..-'-- ---------- .. ..
(Thisie ` 310's=\ INTERIOR LATH ' O•�klij\U1.j "���,..
hwaxa dollars
aIOO)orlessa,: 311 - SCRATCH COAT
L.1'estfil,onm
drat in 'aeeurtit workfar wNthis hpc, t isissud;l 313 - ROOF NAIL,,. ,c-I
lnen s••"I•�'!++•sn, ..
t ply any oymendwestobaom w63xuotheWwkcti 501 - FINAL ELECTRICAL ENERGY
Cbmicant ran laws of California I Date
Applicant 502' - FINAL PLUMBING ENERGY.
NOTICE TO APPLICANT.IL eller making this Certificate of Exemption,you should - -
Z become subject tothe Worker aCompensation provisionsofmpLaborCode,yoamast 503 - FINAL MECHANICAL ENERGY
O ronhwitti comply with such provisic s or tis pewit shall be destined revoked.
z " 504 - FINAL BUILDING ENERGY;
(Al o"t "" CONMUC11ON LENDING AGENCY '''
E".' 1 hiaby affirm that tete E a conswitidn lending agency for tAi performank 505 - FINAL ELECTRICAL _
"co"
mi work for which this i is issucdISec 3097,Civ.CJ L
�.— an^: _ _ 506 - -GAS -TEST
(� tandcr's Name"'
(st.z real,sAdd s, - .. 507 - FINAL PLUMBINGIi ,;1, T.
V�O L comfy ion I have read this application and stem tat the above information is 508 - FINAL MECHANICAL
•La..E„ cuwecl agree to comply with all,city and county,ordinin es and state laws relining
Oet�
to Wilding constriction.and lsimbyauthorize rtyrtxntativopfthiscity menter upon 509 - FINAL GRADE
W theamve-mentioned property.for insecaonpurpoxs. 510 - FINAL PLANNING
vc
'�`.0. (We)agree to sa ,mdemnHy and kiephawlesi the City of Cupertino against
(A .........ce.iudgrema rose erd expenses which may in any way co t against said 514 - F NA P WORKS
(,) ,Z Ciln consequence of the 8nming of this permit. era
LI NT jNDERSTA DS AN WIELCOMPLYWITHALLNON-POfNT•' Issued b Dale
0 R GULATIO y'
St�iumrt fAPPl c AC wO s. 1 Re roofs
HAZARDOUS MATERIALS DISCLOSURE
W II tie-pplin t a f tart W Iding aavpant tart«hurdle nn tloav twpde Type of Roof
defined by me Cuparmo Mun.pal Cod Chapter 912,adme Health and Safety
a .•ii, l / !-
Coda.Section ) i�,6Hs1 -,t Y t .\, t s 't! '
__Alf roofs.shall be inspected.priorto any,roofing material being installed.._...
a
Will the applicant or future Wilding occupam use tquipmpat orpevices which if a roof is installed Without first obtaining an inspection`, l agree to,relnove
emit haaidoe air conuminanu a derined by the'Say Aura Air Quality Management
Dinner? % .�❑No. 11 ' _ all new materials for inspection. Applicant understands and will comply with,all non-point source regulations.;,
(I have read mi heeii ,materials ru uitemmts under Chapter 6.95 of me
1� e
a✓tfr' its HWt&Safety Code:Sections 25505.25533 end 25534.1 understand that
the Wilding dues not currtmly havea¢non6 that it is myrtsponsibility to wtify to - -
Ccyl f the requirtmcmi which most bt Yuri piici to isommicpbf a CeniOcite of
a
"" Y',' Signature of Applicant DateAll roof coverings to be Class"B" or bettercar ambrair agcni" '! f. am,
D: .• ...... .. .. . . .� ., ... ... .. - i OFFICE. ..