05100139 CITY OF CUPERTINO (' R•�8rfi ;r.;.5^,m
BUILDING DIVISION PERNIITCN�'TtACT TFTI''O�,RMAt TTTs ,
BUILDING ADDRESS: THOMAS E HARRINGTON PERMITN.05100139
22150 HOMRSTRAn RD
ER'S NAME: PERMITISSUEDATE
THOMAS E HARRINGTON 105 F
E: SANITARY N0. CONTROL NO.
ARC HITECTIENGINEER: BUILDING PERMIT INFO
'BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION Job DCSC(I Gon
leiI hereby affirm Nn 1 am Ilemsed under provisions of Chapter 9(commencing P
with
Section 701.0 ofD)ridon 3 often Summa arM Professiam Code.and my Ikeme is
in ruilfareeand ercen FOUNDATION ONLY-PESTS COFFEE
2 Llcetw Class Luc.
M Da¢ CSDECr
ARCHITECTS DECLARATION
I understand my pians alNl be tacit u public records
u
Licensed Pm(csdonal
5
OWNER-BUILDER aexempt
DECLARATION
Com em
I hereby atne on I a1.aumpt!noon the Cantrmmra Lienor Law for the
3 p o following reason. perch comer03 , ,an r. in P demob Cod=:Any city at mangy
$� which requites a permit m amsdrKk alar,vnprow,demnlsh,or repair any unocture
_t ire
OHM k is l svusrcpu rtquires dm applicant lorsuchcw pen we&Li0k a signed sucmm
< that in is intsmde.ismr �ode providaasnt thcContrecerus file claw(Otaper9 Sq.Ft. Floor Area Valuation
E€B (eomewrong with Section 70DO)of Division 3 oftho Busineuand Pmfeuims Code)or $40000
— than he s concept ticrefrom and Ne bass for The al exemption.My violWon of -
SaTio,7031.3 by any applicant far a permit subjects the applicant to•civil penalty of APN Number Occupancy Type
not mom Nan rive hundred dollars($500),
0 I,u owner of W pmpmy,or my wployen with wger u N=4ml=mmpemdan,
win donde work,and the structure sent immudedar oRued(waale(Sec.7044,Busier. Required Inspections
and Ra(esdou Cade:The canlineWeS LJceau Law does ree
t apply 0 an ower Of q P
prepeny who builds or imp.therm.:and who doessuch work himuJf orThrmgh his
owo employe,provided newsreels improvements art not Wended ora@ted forsYe IL
however the building or Wprowm nt s mid within one year Ofeorepkdon,th<ownv- .
bull 0 haw tie curds.of proving dun he did et build or improve for lospau of
7son
1.as Owner of the property.un aselusively,contracting with licensed centranars M
met=the project(Sec.7044.Business and Profeedom Code:)The Contractors U-
rise law does ret apply to an ower of propert"ho builds Or minnow Nereus,and
whtafor such vmkma with conuacmr(s)if... d Furrow to the Contractees
Lleanne va Law.
❑tun Lunda gee .Bl PCfor '
Due /
WORT 5 ON DECLARATION
reby affirm under Wy afperjury nm of the following declandonsi
I tum and will mountain aGuiOma ofoossent a self-alum far WorkersCamper.
sstion,u provided for by Section 3700 of dee labor Cade,for the perle mbeen of the
work for much Ns permit is issued.
0 1 haw and will maintain Workers CompemWan huWanca,u rtgaiMd by Section
3700 oftee labor Code,for the perfam onca ofthework Ire which tits permit s Issued
My Workers Campasstion Inmrutn carrier and Policy number tae:
Cori. Policy Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thsmetton sed not be completed Irdc permit Is(arson hundred dollua(x100)
or kat)
I certify Not in the Perfomaus oI th won c for deb this permit s issued.I"I trot
employanypetmnin apYmmerm lmujectu Uc wohers'rampenudon
Lava ar Cal' le
Appllcanl
NOTICE TO APMARM If.ARM mak' S u Cm i0cae of Eonempdan,you should
become orb iethe Workers Compe 'on pmvldans or On lahnr Code you must
w,0 faMwith comply with such pmWSNm Ns permit shall be deemed revoked.
Z,~0. CONSTRUCTION LENDING AGENCY
(..t Iherehy.M.thu Nero Is a eotWucden lending agercT(-I Ne perfarmuce of
CL> he work for which tits permit is issued(Su.3177.Ch,C.)
G~n. tondos Name
U O ltnJeh Address
1 certify that 1 have Had this applicuim and sum thu the show kformades is
M ^". cor 1 agree to,comply with all city and county aNinaricu and atak laws misting to
0 gr.^1 building construction,and hereby mNorim¢preuestous of this city in enter upon Nc
W ahme-memidgm nts,cis ran Inspection Fugrout
fy.t� Ty I%)agree to taw,indemnify and keep barmkss the City of Cupertino aphuT
it y liabilities.judgments,eau ands nus which may my way rerun against sold City
V Z APPLICAUNDERSTO NDf NO WILL COMPLY WITH ALL 0 01 Issued by: Date ��p
F33ULA
t 1 Re-roofs J
n mofApplic one tar Diane
AZAR OUSM TERIALSDISCLOSURE Type of Roof
Willtheapplicmtor been building OccupmlmamorlearWlehavardummaedd
u defie0 by t e Cupenion Municipe ode.Chapter 9.13•and the Health and Sandy
Sema^3553x(.)? All roofs shall be inspected prior to any roofing material being installed.
Yes O
Will Ne applicant or stare Ing Occupant tau equipment or Jerim which If a roof is installed without first obtaining an inspection,I agree to remove
J' It hv=Os air emounlnanu 0ed by the Bay A.Air Quilty Management all new materials for inspection.
District?
❑Yn Nu
1 have mad Ne hvardous mu=das requirements underChapur6.95 nrdteCalifor-
niaHulN&Safety Cade,SaJ 35505,35537 and 37574.1 unJcrsuM If the ilJinp
J
come
mama NN it4 my respeaslhilirytotroti(y do Y 1ofIM
tawhkhm prior uaeeofsCmifcaeafOcL/f/ Signature of Applicant Date
er ar suthafi qc t one
All roof coverings to be Class"B"or better