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02050070 (2) CITYBUILDING DIVEISSIIONNOPERMIT CONTRACTOR INFORMATION: Ib25 p'Cyq 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 SV2, 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.