02050070 (2) CITYBUILDING DIVEISSIIONNOPERMIT CONTRACTOR INFORMATION:
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BU I<� "Fb TELLING RD WATER QUALITY PLUMBING PERMIT NO. 02050070
I12°L$9M JEROME R AND ATSUKO T T 1860 ALMADEN RD T�'�'cfJT/r�n2
t PHONE: (408) 267-9330 SANITARY NO. CONTROL NO.
C sea AItCHfI'-Cr/ENGINEEk: BUILDING PERMIT INFO
O BLDG ELECT PLUMB MF.CH
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LICENSED CONI OR'SDECLARATION COPPER REPIPE PMH Yi tion
fLIC
z thereby e ,hallamlicensednudununderprovisionsof m
Chapter
with Sectio ](Nq)of Di vision.of the Busi s nd Prnfcssions Code,and my license
d d ,
3.pia ce ss eC. 4 .a 3
O i u ate s - Contmcmr
i 3 u y . A CHITECrS DEC ATION
0 g I understand my plans shall be used as pu6hc mcorul
IT
Y
i m,O Licemed Prolessionil
OWNER-BUILDER DECLARATION
'u5 I hereby affirm that I am exempt firm the Comment's License Law for the $4000
f- a following rtmon.(Section 7031.5,Business and Professions Cade:Any city or county
f F C which equ permit( construct,aIlex improve,demolish,or rep y swclum
63C$ prion,tots'issuance.also rol the applicantl 1 Permit file a signedslatemenl
that He is.licemedPrsaanupdep .tons ofthe Contractor's L La (Chapter9 3CS .3pk ff'hOE a.,.; i, ,, Valuation
more ncingwth Section]000)of Divi ion 3 of Business adP r 'm,Code) ),�;'; ,-
or(hal he is nempi themfrom anJ the basis for the alleged esempoor.Any vodi n m '
-of Section 7031.5 by any applicant for apron subjects the irMlicanuo a civil penalty
.of no,mom door five hundred dollars(s5oo). 202APN16QN16AEIRFLOOR PL B'ING.. Occupancy Type
01.as ownerol'the property,or myemployees with%s,cs a5 their sole compensation. 301 — ROUGH PLUMBIN
-will do'the""work:and the smalmre is not intended or ofemd for sale(Sec.70,14, _
(BuSinesi and Professions Cale:The Contractor's Lic<nu Law docs not apply m an S
FT= P4
caner of property Who buuda or impmves thereon.and who dues such wo,k himself 507 - FINAL PL B ING
or er his own bony es. ended that such ennism,is sol are not emended of _
-oRBcd for sole.If,M1ow<vcr,the builders -'m rovemem is sold within one if � �� "' ' ' -' "' "--'-""'_...-_ .__.. _ .._ ... ..-._..
completion.for me owner-balldcr will have the burden of proving that he did not build or s '
improve for purpose of sale.). AA
OLas roflhe P(SPenyam Buorev<lycontr¢dnion,Clicensed e Contro to
- - LED-
rust the project(Sm.]Baa,euzin<ss and Professions Cade:)The Commcmr's -
caret ,
aiam I�w tat not appy m an owner th progeny who builds e uns a thereon, jj V
:. a .Commis commas forsuch protects with.a convvclortq licensed.pursuant m the F11 3.-O ZOOZ_.. ..
C manors License Law., .. .
_ ❑lam ex<mPtunQer Sec.. .B&PCfonhis rcaun • J
Owner ' .: Date UAL®IfVC.a
WORKER'S COMPENSATION DECLARATION
' 1 hereby affirm under penally of Perjury one of the following declarations:
❑ I have acid will maintain a Certificate of Consent to self-insuu for Worker's
Cmo,matinn, as provided to by Section 37W of the Labor Code, for the
performance of the work for which this Permit is issued.
- ' ❑I have and will maintain Worker's Compensation Insurance,as required by,Scetion
37W of the lah ,o,Cold for me performance of the work for which this permit is
isiu d My Workcr'eCompensation'Immance comer and Pol'y robe are:
C i�r toy
_C in.A'L�CF,RTIPTCATION OE EAF,111PT1 FROM WORKERS t
COMPE95A'fION INSURANCE" �' `
� 'ITnts uctton need nen tie camplcteJ T ibe permit rs far one h mdrcd dollvta ,, I s s •1'I'
(31 WIm IeasJ '
1t c.mplY that in the n in any.mann the work for emiet this permit a;sued;I r .. _
shall not'cmploy Laws
personin any manner io a m became subject to the Workcti t -
Applicant-tan Wws of Californiaalif .Date
NOTICE TO ctAPPLICAN Work:If,after makmg n p Ceniheme of Exemption:you should
becomeh Comply with
the such
visions 1 this provisions of the Labra Code,you mus
Q 0 fonhwit6 comply wit-such Provisions or rets permit shall be Je<med revoked.
�.,4 .Is( t:r••^:;CONSTRUCTION LENDING'AGF,NCY' -
(✓ ""I hereby affirm mat tM1cfe is dsobswciion lenJinB agem'Y for the performence t n . ._
W..a nftheworkforwhich,hispcnmlisissucd(Sec.3W7 Ci¢C.) tf�
Q Lender's Netite•::. -"5,Z 1.6116s AddressU 0 ccnify{hat I have read this application and state that me above information is
W L. ivrreci.Ivgfectocomply with all city and county ordinances and state laws relating
mbtiildingswinn:and hereby amhoiizc rcpduma,ivcx of rets cilymcnterupon
!r] te .1mloner"ndcd Pmpeny for itnpeaion purposes.
p. (We)agree to sate.indemnify and kap hatmless the City of CupertinoagainstV) liabilities,judgments,cots and expenses which may in any way acerae against said V HGllyIn COnS[Q11[n[e of IIIC$fanlln$of ISll.
HPPLICANT ONCE STANDS AK FILL COMPLY WITH•ALL 60 GPOthT
_ 3v-ER ,u c7 _ j�r',l� Issued by: Date
Si,mmm of App ucomos t' ".'Date Re-roofs
' HAZARDOUSMATE RIALS DISCLOSURE
whm upp&cu t rt rcbuildmg«c pant toreornandl<har sous n.erHal _ ..Type of Roof. . .. . . :, _. - -- - _
a d f ed by the Cupen n Municipal Code chapter 9.12 and me health and Safety ,
s ..- ..
Ciid Shelia
ct oft 25532(a) v - tjkl' c �'�t
a
All roofs shall be Inspected priorto any roofing material being installed.
Will the applicant orfuture building occup ntuseequipmentordemaswhich If a roof is installed'without first obtaining an inspection; I agree'to-remove
emit hazdrdoas air contaminants as defined by the Bay Arca Air Quality Management
District?: -. all new materials for inspection. Applicant understands and will comply with
1) oyc, ( "° all non-point source regulations.
t.,
f h read the hen dous numadials requiumemv under Chvper'6.95 of me'
California Health&$ufny Cade.Scetions 25 OIt 25533 and 25534.1 understand that _
ifdue bhildin8 does not currently hmcatana It it
my responsibility to notify the
occupant of,hc repo,mul wbich must If
'n.,1.issuance of a Cenificide of
°°'"`y' Signature of Applicant Date _
Dat'�� All roof coverings to be Class "B"or better'
er or zed a 1 a
'.},,:,i .,r•d, ..,d .. �. .. ' -: __. .... :. _,. - OFFICE.