03010157 (2) CITY OF CUPER'11NO
BUILDING DIVISION PERMIT ayCONTRAC�T,OR INFORMATION
x. vs ,
BUILDING ADDRESS: SHADYGROVE CONSTRUCTION PERMIT NO.
602 STENDHAL LA 03010157
WNER'S NAME: 6276 SHADYGROVE CT APPLICATION SUB DATE
RUSSELL LARRY D AND YVONNE S 01/27/2003
ONE: (408) 252-3500 SANITARY NO. CONTROL NO.
ARCIUIEC %NGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O02 LICENSED CONTRACTOR'S DECLARATION
�ao
ajr 1=. 1 hereby affirm Ino 1 am licensed under provisions of Chapter Description
o(commencing p
a� with CScclilof Divisinn;of NC Buxincss anJ Pmlcasinm Cndc.anJ myliccnse is'1d in tun rarereand and cffCC1' SEWER CLEAN—OUT pg���
Zpq4 License Class Contract.,
" s�ALE[�
O N t:qS Dale T"SDECr
N x_, As small ECTS DECLARATION
�� 1 understand my plans shall M used as public menrds _
a0nt�
Licensed JAN 3 0 2003
uai 3 LicensedProfessional
1"1=0
OWNER-BUILDERexemptDECLARATIONrriou
a�i f I hereby affirm that 1 um exempt from Inc Camrannr's Liccns Lew I'ur the ,
i 600 following reason.(section 7031.5,Business and Professions Cone:Any city or county �'
X
$Pi whim m requires a permit construct.after,improlrunm
aflutter.demolish,or repair any su
w— pdono its issuance,also requires thcapplicantfar such permino Glc a signed statement .r1
izsus g that he is licensed pursuant to the provisions of the Contmclnr's License Law(Chapter 9 Sq. Ft. Floor Area $YOGatlon
F0 (comncing with Section TXXB of Division l ofthe Business and Professions Code)(it
y $ that hmeen exempt therefrom and the basis for the alleged exemption.Any violation of
Section 71151.5 by any applicant for a pcfmil subjects the applicant to a civil penally of
net mare man fi.hundred dollars($500), be Occupancy Type
1,as owner of the properly,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:"Me Contractor's Litt.Law does not apply tu an owner of 202 — UNDERF lJlt a ffle ?M'
progeny who builds or improves thereon,and who doessuch work himself or through his
own employees,provided that such improvements ase not intended orolfered forsale.If, 301 — ROUGH PLUMBING
however,the building or improvement is sold within one year of completion,Ne owner-
builder will have the burden of proving chat he did not build or improve for purpose Of 302 — TUB & OR SHOWER
sale.). 502 — FINAL PLUMBING ENERGY
1,as owner of the property,am exclusively contracting with ficial convectors 10 506 — GAS TEST
onstrucl the project(Sec.71144,Business and Professions Coda:)The Contractors Li-
tt.law does not apply to an owner Of property who mumorimpomesthemnn,and. 507 — FINAL PLUMBING
who contracts for such projects with a conwamm(s)licensed pursuant to the Contractors
License l.aw.
❑1 am exempt under Sec. .B&P C for this reason
or Data
WORKER'S COMPENSATION DECLARATION
I hereby aRlm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate ofComwnn to self insure for Workers Compen-
sation,as provided for by Section 3700 of the Labor Code,for the pediormen,of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
171M of the Labor Code,for the pertianumec of the work for which this Nord is issued.
My Worked Compensation Insurance carrier and Policy number am:
Carder: Policy NO:
CERTIFICATE OF EXEM(TION MOM WORKERS'
COMPENSATION INSURANCE
(This section need not be ciandewd if tbe Mmil is for one hundred dollars(51(X)
or less.)
I"
mal in IM1e r4amance of the wait for which thio permit is issuetl,I shall nm
empluyany a snnerso became subjenmlbeWrl 'Cat lion
Laws of Calif
Applicant M
N�tQLTO L ANT: al t g is cat m
m of Exemption,you should
MesTme mote to Ire Wars Compensation provisions of the Labor Code,you must
O Z forthwith comply with such provisions or this Permit shall be deemed divided.
z Q CONSTRUCTION LENDING AGENCY
N+ I hereby affirm Nat there is a constriction lending agency or Performance of
111 t7 the work for which this permit Is issued(Sec.NN7,Ci,C.)
W� 0 Lender's Name
z Lendeis Addmss
U 0 1 certify that 1 ban read this application and sum that the above information is
P comet.I agree to comply with all city and county ordinances and stow laws relating 10
�U building convection,and hereby authorim representatives of this tiny to enter upon the
W above-mentioned propcny for inspection purposes.
Fa (We)agree to save,indemnify and keep harm less the City of Cupertino against
rat liabilities,judgments,costs and expenses which may in any way accree against said City
,U 7 iAnPPLscyuc&Uf me gSTANDranting f this radial.
WILL COMPLY wI'ITI ALL NONPOINT Issued by: Date
❑❑ SOURC: 'G ONS.
Re-roofs
Ignam fAplicaOfZARDOUSMATGRIAISDISCLOSURE Type of Roof
Will Ne app cam of future building occupant store of handle hazardous maedal
n defined by the Cupenino Municipal Code.Chapter 9.12,and the IIcahn and Safety
me,semen 25572eaT' All roofs shall be inspected prior to any roofing material being installed.
❑Yes �No
Will the applicant m future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
District/
❑Ycs \ Nn
1 hart mad die hazardous materials requirements under Chapter 6,95 of the Califor-
niaHcallh&Safely Cods,Scmiom 25505,25571 and 25574.1 understand thv if the,building
does not cum nate u tenant,Net i1 is my resrymsihility to omit the rccupant al the
mqui men hmunbe 'nr un issuance of Jma of apanc. Signature of Applicant Date
aamariz ag I Dam All roof coverings to be Class "B" or better