01110106 CITY OF CUPERTINO
BUILDING DIVISION PERMIT 'CONTRACTORANFORMATION:
BUILDING ADDRESS: PERMIT NO.
6327 BOLLINGER RD 01110106
OWNER'S NAME: APPLICATION SUB DATE
CUTSHAW CARL L AND AGNES G TRU 11/26/2001
PHONE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING P RMIT INFO
BLDG LECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
5 h I hemb tBnn that 1 am banned under f Chat 9 ta°mmenrin Job Description
gS-o y a provisions c per g
wt-m is in full on]WO)efect. en Sof rhe Business and Professions Cade,and my license REPLACE MAIN CIRCUIT BREAKER.
i m f so is er full force and effect.
a a.¢ License Clan Contractor a Cri
Dale S DECLARATION�O F
y ARCHITECT'S DECLARATION
2 so1 understand my Plans shall be used as public records
OO Licensed Pr°I'eeel°nm
oOWNER-BUILDER DECLARATION
calao 1 hereby affirm that 1 am exempt from the Cia,una m's License Law forme
t_za followingreason.lSeaion]03L5,Business ane Professions CWe:Any city or ceunry $400
z which requires a pemlt m tconsumer,alma i nprove demolish or repair any structure
n 3= .,pr not <al rectums thef rSuch Permt1 file Signed statement - ..... . .__.._
tq the blemeA -rmi It the iio fthe Comraaor L Law fCha ter9 _._al _--_..___..,
P q P P SQ y� LL,q Valuation
(commencing with SecuZoO� finial' 3 fate BusinessndProfessions Cade) 'r , �4y3' 0711���r��llV Baa�Si� rLicr.'S�
or that he rs'ede'rnpr therefrom and the basis for the alleged exemption.Any violation
of Section 7031.5 by any applicant for v pemrit subjens the applicant rn a civil Penalty
of not ttrore than five hundred dollars($5M). 304"PN-KC7UgiH ELECTRI Alii Occupancy Type
❑1,as ownerofthepropeny,or my nof inwithwagestheirsolecompensation,
will-do,the'workf and the structure
cre is-ntlr intended'or'offefe red for sale(Sec:7044,' - -
Business and Professions Coda:The Common'a License Law does not apply to an 505 — FINAL EE£3Ln!1Y011M1:StionS-f'`'- '
wner°f propeny Who builds or improves thereon,and who does such work himself
or through his f pl yeas Provided that h p r. accordintended
oRe edf le If It thebld' g p' -m wld. .th y (. .... .. -- _._...... _._ ___.. . -__ _. _._
cn plat t builder Illi theburden fp ng that hdid rb Id or
tap a ryu f )
ne fth
ponporry,am exclusively contractingw Nlicensed comma to ,-
construct the project(Sec.7044 Business and Professions Cud )The Contractor's I,
License Law does not
apply to owner of property who builds
improves th
andwhgns f h p fCaw tha connecloo(s).1 Dud Pursuant to the
_-..DC1 11.0__Canton rsLieense Law.
am
xe pt under Sac.' 9QO•t'
. __...._
B ffi P C for this reason Dat .
0 er WORKER-SCO _ENSATIONDECLARATION BUILDING
1 hemby afrum under penalty of Rerjury one of the following declarvtinns:-
❑ 1 have odd will maintain a Cenificare of Consent to self-insure for Worker's
Compensation, as,provided for by Section 3700 of the Labor Code, for the
performance of the work for wh'mh this permit is issued.
❑1 have andlvill maintain Worker's Cmpemnripn'Insumnce,as required by Section
--- 37M of the Labor Code,for be performance of the work for which this permit is
y OM WORKERS
' iss dM W�sPICATION ORIEXEMPTIONePRNCE _
• _� c _
%
1.
•. n 1 _..._. ..
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COMPENSATION INSURANCE"
(Th s sect on.need not be completed if the permit is for one hundred dollars
($1009 ,leas.) - -
Icndo,aninthe erpeinanyaeorr rkf tiSusct rein ed1 .L1, r,l -i• j
C ml not employ any Person m any men vs r°became subject t°the Workers' "
o =
Co p at on laws of Cardboard.Date', "
... . .. . ................ . ........ .__........ .. __. ... _._.-._. ....._.-..__-
ti
NOTICE TO APPLICANT: after
pmakingth's Cenf_c.a_¢. fExemption,you
Ze subject the W6kecs Cons r provisions of LaborCade you most
CC foranh comply with p thispermit hall be deemed revoked.
CONSTRUCTION LENDING AGENCY
i
_ ..... . _ _
I he brk y tBrm that th s a coosuun n lending eg cy f r rhd performance 'It) t
W.(�
Lender's Net iv.C)
of the l e ndr thatclhhae rtatl this adids?e1uht is s lanai on and that the above information' - __,._. _...,. _...- .._._ _ _.
�.O -_.._.... .. ....- _ ..... _..__
� Le der Address
V PP
W [.y correct.I agree m comply with all city and county ordinances and state laws relating
m buildingconxnuchim,-arid hereby authorize representatives of this city to enter upon
the abowrothponed Progeny for inspection purppso..,
(We)agree to save,indemnify and keep harmless the 61y of Cupedino zg mat
liab I r s in dgments, r d expenses h h.may in any ay rue against said
Ci quenceofm g ting of thisPermit.
' - ".,;
PLIC UNDERST S, W LI COMPLY WITHALL NON=POINT
•oUR R Gr L 0 ear. , / zG^m 1 Issued by: _Date [
79 tg em or Apphomm/C ntron, •Dare!—',"p Re-roofs
AZARDOUS MATERIALS DISCLOSURE ';
a definedb N Criterion.f r tab Id dgce p nt st reo hannleh rti l mate I -Type Of Roof,.
Municipal Cod Chapter 9.12.and to Health and Safety
❑Y s a a) D t All rOOfS shalla x r l 9. tayt`rme t i i= t :'i s,l . .
Cod Section 25532( �'
pN° be inspected prior,to any,roofing-material-being installed.
_ . _
,.,, W111the_pyre torfuture defined
g chelRuseequp t e ana emnt If a roof is installed'without fust obtainingan inspection, I agree'toremove
earn
m t harard az defined b the Ba Area A y Management P
contaminants y y Q al t
Gi all non- omt source re lahons understands and will comply with
a new materials or inspection. Applicant
ti: P g
I h v tead'!he hazard s material requirements bane,Chapter 6,95 of the
aldomra Health&Safer Cotic,Sections 25505,25533 and 25534.1 understand that
,if bId nB does not curremlY have a tenant,that it is my responsibility to notify the
a ant of there drearmus wh ch must behe, " `- t
P issuance f 1 Ceriificare°f
Oc a ane . :...:•,
L' P Signature of Applicant Date
.-_. _ _
--owner P turbanned eg nr Date., All roof coverings to be Class B or better
r
.. ' - OFFICE
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