01120007 (2) CITY
DSONO
IVIiiNPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRFSS: PERMIT NO.
20416 VIA VOLANTE 01120007
OWNER'S NAME: APPLICATION SUB DATE
SHARON KOHLMANNSLEHNER 12/03/2001
1 PHONE: SANITARY NO. CONTROL NO.
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L+�i O O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
k 0— BLDG ELECT PLUMB MECH
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Z S v=Ni i LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby a)of that 1 um of
B under provisions of Chapter 9(commencing
P=L1° with SeniOn"IOOOI of Division 3ofthe BuxinaProrex.i°ns Code.mid my B<en:< FILL IN FLOOR OF INTERIOR LANDING AND DEC
K Y f J ism ru f sv and
effect.
z m a License Lic. )s��
%O d 0 D c — Contrraasars]]
F u3—.O In ARCHITECT'S DE[yA ATIO A L �
g I understmd my plans shall be wed as public occurs
NOV
n Licensed Professional 13 2002
a.o OWNER-BUILDER DECLARATION n
1 hereby affirm that I am exempt from the Contractor's License Law for the A �+
L i o- following reason.(Section 70315,Business and Professions Code:Any city or county ^
which requires a pemm to constoct,alter, m uun
improve,demolish,.r rcpeany sure ''� n•9 minn g �f n $20000
.prior to its issuance.also inquiinstheapplicam for such permit m fleaaigrud staeme t -
d30 that he is licanvol pummat 16 the prosisions at the Contractors License Law(Chapter 9(commcnciScction]Osion3ofthecaar(d ProfiCode) a0.5�o.:r� e.fa
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Valuation
or that be is Cst:mpt hcicfroi 'mdl the basic frzthe alleged exemprvyAnyviolation
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of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty mmohrrsr
.°fnotmamthan evehundred dollars(5500). 101APN PN ditATION OccupancyType
01,as owner of rhe property,or my employees with wager w their sole compensation,
-will do rhe work.and the smuctme is no,intended or offered for sale'(Sec.7f W.
Business and Professions Code:The Contractor's License Low does not apply to an 103 - UFER Required Inspections
owner of property Who builds or imposes thereon,and who does such work himself
or through his own employees,provided that such improvements are not intended or . . 104 . - ..REBAR
'offeal tortilla.If,however:the Wilding or improvement is sold within one Year of ........ . .". _..
6impletior.me.wner. bolderwal have the burcrnnfposingthat he did not bmicim- 105 - ANCHOR BOLTS ""1''
mp'°vernrpup.a.r le). 106 - SEWER & WATER
01.as owner of the property am exclu.vively contracting wiih licensed Contractors to 202 - UNDERFLOOR PLUMBING °•
onswct the project(Sec.7014,Business and Professions Code:)no Contractor's
License I.aw does not apply to an°caner of property who build,ar impmves thera.., 203 - UNDERFLOOR MECHANICAL
I .'. andho contracts for such.projmu with.a.contr we s).licenscd pursuant to file
Contractors License law. 204- - UNDERFLOORS-_FRAME' -
❑Iamexempt undcrSec. .BffiPCfor this maso° 205 - UNDERFLOORS INSULATION
owner Date 301 - ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION
302 - TUB & OR SHOWER
. Ihereby af hat under Penalty ofPerjury one ofinet°Imwingdecimations: 303 - ROUGH MECHANICAL
0 I have and»;n maintain a cediheata.f Conant m self-insum for Workers 304 - ROUGH ELECTRICAL
t Compensation, as pmvidcd for by Section 3700 of the Labor Code, for the
_ 'verhrman<=or me wart.rnr which mi,pennh;r ir.aea. 305 - FRAME
_ 01 nave and will mainmin Worker's Companion..Iriiurana,us mquirtd by Section 306 - HOLDOWNS
3700 of the Labor Code,for the performance of the work for which this permit is
moral.My Workers C pe sation, wmnce d e and Poly x pre 307 INSULATION
Gatti At,:' ,� A: P. la44b6c, 02 308 _ SHEETROCK. ,,, V. 1. ;.
' { CERTIICATIO�ENEMP'f1ONFROMWORKERS,` - t aEXTERIOR LjATH
COMPENSATION INSURANCE° - su __
... .. .. ... I .. . . . . .—. ."..._.... .._ ..__._._.. ___._ ... ..._ _
3TO =; INTERIOR LATH
"•(rnir anion nem not be completed if the Penni,L.for one hundred dollars 311 - SCRATCH COAT
IS 100)or lcssJ _ _
Kofti
_ .. . 313 ROOF NAIL,,,
I mfy Boom
t m the a mfly hacof tW wo=k for cion h th' pc tis rssum 1 +
'xlrn t per yremonm,. mann==..attox<nm ; nI tt m=Work=rs 501 - FINAL ELECTRICAL ENERGY
Compenstu mi Laws 'C.
Carfomna.Dam
.Acpfcom - 502 -' -FINAL PLUMBING ENERGY - -- - - -
.Iscm, AIIIucANr:v.'ane,mdorgthiscCmpcateofErempn.�.you�rnnwd 503 - FINAL MECHANICAL ENERGY
become subjecuo the Worker's Compensation pros cions of the Labor Code,you must
QZhmhwinh comply with such provisions or this permit shall be deemed invoked.
ZR O _ 504 - .FINAL BUILDING ENERGY
"CONSTRUCTION LENDING AGENCY 505 - FINAL ELECTRICAL
I hereby affirm that theoc is o Construction lending agency for the perfoman<e
W.. onhewoafor whlchmirpcmrdlixrszam,(Sen.307.Civ.C.) 506. GAS TEST
Q Ikrder's Name' . ........ ... ..
Z) z rrnde.rAddra:t507 - FINAL PLUMBING
r U laemry tWtlnave r�aa rots appG<mmn and znam mat the aW"e inr.rmad.n is 508 - FINAL MECHANICAL
-'
;er correct.I agree to comply with all city and county ordinances and state laws relating 5 0 9 - FINAL GRADE
U ,budding c"n.umctim.and hereby aunhuriee rtpresemmivex of this city to enter urym
y w theaWve-mmnpnadpmpenyforinspectionpurposes, 510 - FINAL PLANNING
Fs 1' IWd agrcemsave.indemnify andkeep harmlc inor Cityor Cupertinoet void —
z liabilities,judgments.costs arta expenses which may in any way acerae against said 514 FINAL UB C WORKS
V. Cit m con quense R Agranting of ss pcm,it.
Al vruaoERSrnuur wl'coS,IrkrehrnALpr7ouer�Nr Issued b , Date
U F GULATIONS S o Y
,,grm roof ppli on ctor• - Date Re-roofs '�
HAZARDOUS MATERIALS DISCLOSURE
Will m apps t 1 tore Wl1di g <p t t Le ar n al .dart d,ua material .Type of Roof... , . _. _ . . ... ..
as d f oro by the Cu,,tirm Municipill od Ch Pt 9 12,and the H IN and Salary ;. „,,
Code.SrCma-2553_0 i', tt '.F' } ' Asn 6 " 1s1 4 i s t .4 i .
OYea' '`' � 'h All roofs shall be inspected.pnor,to.any roofing.material being installed..
Will th appliceni or futurebWilding a<upa"t use equipirm,.ft or devices which If a roof is installed without first obtaining an inspection, I agree to.remove
m t h a tr co t d,nuns, s def the Bay Art A Q ge
Quality Manament
o t ctl all new materials for inspection. Applicant.understands and will-complywith
0Yes all non-point source regulations.,
I have mad the haonlous materials requirements under Chapter 6.95 of the
'California Health&Safety Cme.Sections 25505.25533 and 35534.1 undernindthat _
if the building does not cummly have a tenant that it is my responsibility ,,notify thin -
m of the reyvirement,x hick u be met prior to issuance of a Cenifcate of
Rll,fpe Signature of Applicant Date
9U
am.atom agent Date All roof coverings to be Class "B" or better ' ,
OFFICE