00050176 CITY OF CUPERTINO
BUILDING DIVISIONPERMIT CONTRACTOR,INFORMATION
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NUILDINGIJR - - PERMIT NO. APV i.
� 5 CRISTO REY DRLptJ�a9� FPMIoJ `F`....
OWNER'S N N 1 • APPLICA'f1ONaUli
�t� W, 5101i=16
MAN CATHOLIC BISHOP OF AN J ' 3-110 E� C#Iflt la 7�
IIONE: - - - - - SANITARY NO. 05 O
6 SIL 428 3 7 3 �R,-o L11 ay S o6
M,Q ARCHITF.CDENGINEER: ` - BUILDING PERMIT INFO
F'D ,.f.G O J•� BLDG ELECT PLUMB MUCH
<i sv 77 TT TJ'b
Zzy$ Iherehr=rLICENSED
mLnseonuMn'ecunndr provisions Hf cn Par S recommencing lob Description
Fzfr with Setif I7000)of Dlvision3al"hbeB."nor"and Prot,"jons Code,mhdmy l'mcnso
m f� is in full fnrcc end 1. '• .
E s w a Littnse Clos- p�q Lie.x 6 S t'9
C.
It, ARCHI"1'IiCT'S OECLAR74W- rr^
aj I understand my plats shall be used as public record.,
oo LicensedPmfessional DRY ROT REPAIR
OWNER-BUILDER DECLARATION -
I hereby affirm that 1 our esampt from the Comruunhr'e Lleenvc Law fpr tire _
C Z following reason.(Section 703 1_5 Bosinexs and Profession,Crab,Any city or aunty
SSG which requires a permit m construe,uhecimpruve,demolish,or repair any structure
63 prior tits issuance,also requiresthe applicanthasten fiction tfile asigned statement
but he :I ecifirs tt be hr .,, f the C t torr Leeavcl (Charter9 Sq. Ft. Floor Area Valuation
' (e g nhSe9 7000) 11), - fth . h el l'
3 B :, :Code)
or $15000
that he is thtmfmm and the basis for the alleged exemption,on,Any violuu,n
of Sation 70315 by any applicant for a peimil subjects the applicant u,u civil Penalty
'If not.,,.,banfive hundred dollars(550o). APN Number Occupancy Type
Ol,as owner of the propeny,may emhl,yees with wage,n,Ineo-wrec,mpeosntMh, 342V75059. m0 '
will do,he work.and the stumure is at imended or o06red for sale Iso.7600,
Business and Professions Code:The Contrai License Law dm%nal apply m an Required Inspections
owner o'papery Who build,or improve,thereon,and who does such work himself -
or Ihmugh his own en,pinyea.prnvlded thin such imp ravcments as nm mended or
offered for sale,If,howeve,the building or improvement is said within one year of r
completion.the owneobuilder will hate the burden of proving that he did not build or -
improveforpurposeof°ala). 515 — FINAL BUILDING ,
0 L to—ne,ud de propeny,arm eedurively contmnting with Fretted a.nnmmrs to
combat,the project(see.7044,Braine„amt Pmfe„inn.Ccdc:)'If.Cmmmemr's
License Law does not apply m an owner,of propeny who builds or improves 0emm,
and who contracts for such projects with a coaracmrts) licensed pnmuant to the ,
Cmaw
urra,License ntoo
eltnderSee
,13&PC fpr thiv ruts,, .. 6
Owner Dae Zee COMPENSATION DECLARATION
I herrby olilno under penahy of perjury one,tone following d,damnimn: -
0 1 have and will maintain a Certificate of Consent u,self-insure far Worker,, Q
Compensation, as provided for by Section 3700 of the Labor Code, for the - -
pcdormunce of Ire work for which lhi.,penult is baneci - -
'%''rhave and will maintain Worker'.,Compensation Insurance.as required by Section
bme,sue
of the Labor Code,for the performance of the work for which this permit in
d.My Worker's Compensation Insurance carrier and Policy number are:
Carrier:-!;.-oR79 F%ik..n Policy No.: %g•OD 163'('7
CERTIFICATION OF EXEMP'T'ION FROM WORKERS' -
COMPENSATION INSURANCE
(This eciaioo need non be complain it he penal,is for one hundred dollars
IS I00)or less,) ,
I ceniry hbm in the performance of the work for which this permit is issued,I
xMdl not employ any person in any manner so;is to becmne subject to the W,rkars'
ComApplpensation inn Laws of Colifomia.Uatc ,
NOTICE
OTI E -
N come subject
APPLICANT:If,Cmr making this Cerincnre of Exemption:you should
become whjan,the Worker's Compensation p..fit shall
of the Labor Carlo,you must _
0 fonhwitb cnnhply with start pmvixinns or phi,pemhit shall he JeemW revoked.
z ..
F .V). CONSTRUCTION a1ONL13NDING AGENCY
a ' Ihercby affiroWhich this NM]itsacsued CIion 097,lending agency for performance
W of the work for which This Ilemhin is issued fSca 309'1,Civ.C.)
z Lender's Name
Z) '
Z lender',Address
V 0 Iccni(y thmlhave read this application and stale tont the above infartnmion is `
Lr. F.I correct.I ugrca to c ulply with all city and amity ordinances and bac low,reIt I,
C.) m holding construction,and hereby nallndo,epresenrlive.v of this city to enter ulam -
y �] the abovnmcntioned propeny for inspcaiun harasses.
fit (We)agree m save,indemnify and keep harmless the City of Cupcnino against
cn
:tie
hies,judgments,ahsw and expenses Ishich may in any way accrue against said
C.) City in consequent of,he grantln,of this pcount. - -
APPLICANT t14DERSTANDS AND WILL COMPLY WITH AL1.NON-POINT
SOURr RF fLAT1� S. N Issued by: - Date If'
Siga�li.no/Cmurairo, Dna Re-roofs
IIAZARDOUS MATERIALS DISCLOSURE, y
Will meappncantorfrmeWodingoccapantsmmmbundle ecookoymaanw Type of Roof B
as defined by the Cupetino Municipal Code.Chapter 9.12,soothe Flealih and Safotr,
Curb,Section 25532(a)” _
G Ye, �''" All roofs shall be irispected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an ins ree'to remove
emit hasanlous air contaminants as dented by the Bay Arca Air Quality Management inspection, I id B
Diibnct4 all new materials for inspection. APP hc4 comply cora I a tLunderstands and will with
•ore, 1cfNo all non-point source regullations.
I have dad the hanaradmi, anal q tmmmin,Chapter
,
es and r ti 95 of the
California health&Safety Code,Sections
el ons 23505 25533 and d 1 I understand
d and,hat
if the building does not currently havetenant,thatti my responsibility, unify the %ors �•Qv
app mi nl the cotta n t. hi n.o b ,priorto Iss e I a C n Weare hl
oaapan � ✓/— Sig ata of ApplicantDate -
store,at mnfloamed agent Dasa - All roof coverings to:be Class."B" or better
OFFICE