00060146 ' CIBUDcmy SIONO
BUILDINGN 'PERMITCONTRACTOR INFORMATION: -
BUILDING AW":16 HOMESTEAD ROAD ' PERnHT"x.00060146
OWNFIi'S N hROL MATTESON APPLICATIObtB LffJ/2000
PHONE: l.Fl SANITARY NO CONTROL
CONTROL NO.
al K ZARCHI'FEC'I LIENGINEER:' BUILDING PERMIT INTO
al,, BLDG ELECT PLUMB MECH
F�ii 1=1 I'I f"=1 • O'
Z O i LICENSED CONI'RACI OR S DECLARATION Job Description .`
F� c In nr mm,mtl licensed d ax of cnaprer9 mammaaa ag
F wimf i 9mm�fp aneBa ;rexinnscae�ahanhyFaaam 120 .VOLT 'SUPPLY TO SIGN FED OFF EXISTINI
1 fall f I cffc 1
�,�6 Date eem„. Lie cal LOT, LIGHTING. , NDERGRND FROM EXISTING LIi
ARCHITECT'S DECLARATION
I end cmcounty pions,,hall bused as Public nenNc
�Y
w 3 p O hicenxeJ Professional - -
u S o LL OWNER-BUILDER DECLARATION
u� 1 hemi affiralgoal thin 1 am rHotn from the Contracessim,C dLicenseAd,c Law co the
C 6 following reason.(Section 70315,Hotness nese and Prolaxs ons Code Any shy.,county -
�' o
Which requires Permit I 'I t 'Jtcrimprove,denol sh,or repair any structure
Pet t oconnote,al req rsth pp'icant frrsach perms flsignedstatement -
morn , n.aepars a tit m p .nn.nnneeo,tmethr 1 L (Cltaptcr9 Sq. FL Floor Area. : Valuation
'(annmmma rig.with Section 900()of IN.kion 3 of the Bnsmepx imd Pmfexxiens Codo)
or that he',exempt therefrom and the basis for the alleged exemption.Any violation
of fiecdon]031.5 by any sildicaut for a pernll minco,,the appla,me Uncivil
penally -
of net more man E,;e hundred dollar,,($5oo). _ APN Npm6ei Occupancy pe
El 1.as owner nnhe property nr my employees w hh wagesns their sole compeusmion, .
will do he work,and me structure is not intended or offered for sale(See.7044, v 5 -
Bnones,,nae Professions Cade:The Contractor's License Law does not apply m an .. required inspections
owner of properly Who builds or improves thereen.and who docs such work himself
or through his own employers.provided.that such improvements are not intended or
offered for sale.If,however,the building or iimprovement is sold within one year of 304 — ROUGH ELECTRICAL
"„noeranflames, r-muederwwnaaathebnrdennfpaaingmathedidnn,nnnaar ,501. — FINAL ELECTRICAL ENERGY
improve pamoxea 7 ,
01,as awnararme prnprnr.nm eadmlvelr ennrarlmgwiln licensed contractors to 505' — 'FINRL_ ELECTRIC
construct the pmjem(See.9044,Resines,,and Professions Code:) Tire Conanmar'x -
License Law does not apply to an owner of properly who builds or impmvcs thereon, .
nd who contnmts for such projects with a comrunork)licensed purmant to the
Centel License Law. / is
El baa,exempt under under See. B&P C for this reason
7.
Owner. pate ®
WORKER'S COMPENSATION DECLARATION • `./
( I hereby affirm under penally of facility one of the following declarations:
Cl I nom and will mountain a Certificate of Consent a,self-insure for Worker's
Compensation, as powidad far by Section 3900 of he Labor Code, for the - _
parfannanee of the walk far which this permit is issued.
❑1 have and will maintain Worker's Compton Insurance,as required by Section
3900 or Labor Code,for the pedoodanmhsm ce orcin work for which his permitis
issued.My Worker,C�ompensati�n lns,watt carrier and Policy container we:>)
Carrier:� Policy No.:
CERTIFICATION OF EXEMPTION FROM WORKERS'
.COMPENSATION INSURANCE - I
(This section need not he completed if the permit is for one hundred dollars
($100) It,,.)
1 codify prat in the performance of the work for which this permit Is issued,I
shill not employ any person is any manner sm:yy m bt.c su�h�m the Wolloo,' -
^� .CnmpensotloryYfw nt ,Il fn 'a.Dam t0 - -
Applic;mt ”
NOTICE TO AP (CANT.11;after making this Canlficale of Exemption,you should •- - ,
became subject oldie Worker's Compensation provision,of the Labor Code,you must
Q O mrthwim comply with such provisions or this permitahall he deemed revoked. ,.
w
rA
CONSTRUCTION
nation NG AGENCY ,
ai 5 1 Barco,afli:m that mere Is,nmol(See lending e.C.) .l'nnhe perfnmumce
W of the work for which mix permit is issuul(Sec 309'1,Civ.C.1 - , -
Lender's Name
Lender's Address .. ,
O 1 certify that I have read this application and state that the move inlinnmtion Ix
W correct.1 agree he,comply with ell city and county anthrones m and stelaws relating
Q V do bulldin,madmmian,and hereby authorimrepresentatied,nfthis oft,to enmrnpon
�y ry
the ab ,et ed Propertyf inspection ,.
a (We)agree ms em
Indnify and keep bot mess the Cly of Cup Winn Lapdml '
Vn liabilities.indfirmens,c t,and calsonses which may in any willy,accrue against said
V z City' q e th g i s ofL permit
A�PltP11L�)I,C�A,N�T U,N�DERSTA D[S)sANDWIrL COMPLY WITH ALL NON POINT
VI 6 Issued by:
�ZDate'
Signature offPPlic con DoleRe-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the npap7lormmmbuudCodeComsmra2,andeHwIlilaaniSfety Type of -.
ax defined hymn,Cupertino Municipal Code Couple,Cbapmr 9.12,and he Hrnl@ and Safely ,
Code,Section 255320pp
Oyes INe - All roofs shall be inspected prior to any roofing material being installed.
limitWill the applicant orfuture bmtrlmgswculaint•useequipmentordevtecseach If a roof is installed without first obtaining an inspection, I agree to remove
ill[humrdaus air contaminants as defined by the Bay Area Air Quality Management
er C
mdetR all new materials for inspection. Applicant-understands and will comply with
° °" . Ail all non-point source-regulations.-
1 have read the hazardous materials ragolrolumv,under Chapter 6,95 ofthe
Callum in Henhh&Snfety Code,Sections 25505,25533 Land 25531 1 und,,und sal
if the building does not currently have a tenant,that it is my responsibility to readi the
occupant of the regmram• which mast be met prior to Ixsurace of a Certificate of -
Occu ones. yy -
D f(Jyc1 J4� Signature of Applicant Date
Owner or announced agent- - plate - ' All roof coverings to be Class "B" or better