06090067 CITY OF CUPERTINO
BUILDING DIVISION PE MIT Trl2A0I2Z�`
BUILDING ADDRESS: C & C VALLEY CONST. PERMITNo.06090067
10458 MANZANITA CT
.R'S NAME: PERMIT ISSUE DATE
JAIME CARRILLO & ISABELL SIJARE2405 KLEIN R12. nalnn /�r
PHONE: SANITARY NO. CONTROL NO.
(408) 238-1244
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG EIECT PLUMB PARCH
;co LICENSED CONTRACTOR'S DECLARATION Job Description
1 I hereby apron dant 1 aA licensed under provisions or Chapter 9(commencing
with Section 7IXIIq afDivlsion 3af the Busircvand PrO(rubn Code.,M my Imcnx u
' in full raRnand errem REMODEL-INTERIOR,MINOR STRUCTURAL, BATHROOM
)ga LkencCw Ux,Con' ELECT/PLUMBG,NO EXTERIOR. REPLACE (E) FIREPLACE
Dam Contrscmr
ARCHITECTS
Acus DECLARAT70N WITH GAS-NO SANITARY CONDITIONS .
I� I understand my plans shall he used n public record.
ea Licensed Professional
s or Oat 1 am exempt
from
mDECLARATION
a I"achy.(firm Not 11. axcmpt from site Cssions o :MY
Law for Nc
p o which
msaon.(Salton 71131.5.Business and oc.de oli Code:Any city s county
$ whkh requlma,permit m emslrvc4 alcor,Improve,h Permit erre a sig any strectare
pdorm its tensed c,Nwmgo the ProappRemf forMewchpermr's more,signed statement Valuation
££ Provisions Sq.Ft. Floor Area
t�$ (cat he Isiywhh Satirom DO)ofand
Dtvtstonr.Tacoegelneseption.My
Cadc)w $`45000
e Sac he ta 31.5 b therefrom and du Ants for d j alleged eacmant W Any•doladun of
salon 7031.5MWmMO1emtfors( Permit,ubetsthe applkantw,m 1pa.eyrd APNNumber Occupancy Type
Ilal TOR Nw R.handRd daIIL](SStI:I),
❑L o thew. the =more.R my empluyero wrN wagex sa thele wlale .eompewness
wuldnmewanCode:Inatormxnawaawdoesffersed retApplyManownrof Required Inspections
and Pro,who W code:Tne Contractors rad whoLicemes law acro not hien lf w Owom 9
propertywholoutproaredprowthereon,andwha daosuch work himselrarofferedthroughhis
ownemployees.providedthatwch ntis mid wit in not intended mplonn.TM ownorsale.r-
however.thebuildingorimprovementuhold withinanyear of improve for purpose
owe of
bulkier will have Ibe burden of proving Nn be did nm build or Improve for puryase of
tele.).
0 1,as Owner of the property,am exclusively convecting with licensed contractors W
construct the project(See.7044.Business mW Professions Cade:)The Contractor,LI-
rene law dors not apply to an owner Of pwpeny who WiWs or improves thereon,And.
who contracts for such pmjcou with a como mer(a)lianxd pur.wnt to me Corrientes
Lice.Law.
01. 1 under See .B h P C(or won
Dau CIi0 Cro
Ai Pit, I WORKEPRIPCOMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑Ihaw and will meinuina Cenifiam afConsemwxlblnsurtfawarkebCampen-
sadon,An provided for by Seedan 3700 of the labor Cade.for do performance of the
work for which this permit Is issued.
0 1 ban and will maintain Workers Compensation Insurance,As mquimd by Sermon
3700 of the labour Code,for the performance o(dte work for which this permit is issued.
My Worker.Composed..buuranee carrier sed Policy number are:
Cartier: Paltry He,
CERTIFICATE OF EXEMP 70N FROM WORKERS'
' COMPENSATION INSURANCE '
Crhts secdon need not be completed if Ih Permit is for ore hundred doBam(SIDE)
or less)
I cor ify that in Ne performance of the wah for which this Permit ts issued.I,bell not
employ any ninety manucrxnmbocome rvbjectu the Worker'Comp sedan
Law Arcalif cola.Dau _
Avpncmr • .__. ad` Lek 1.
TO
N077CET0 P CANT:If,afar m.E.g Nis cn10cnc or E mapaon,ya should
became suhb�to the Workers Compensation provisions of the labor Code,you must
.,O fcMwidl comply with such provision or dtis permit Nall be deemed rtwked.
„zi► CONSRUCrION LENDING AGENCY
(.r 1hemby•Ilimt that there is a construction lending agency for the perfurmamm of
�i �: the work for which Nis permit ts iuoul(Sec.3097,Civ,C.)
IG A Lenders Name
.7 Lendee.Addw
V 0 1 certify that I have mad Nu application and suer that the show information is
U. F correct.I agree to comply with all city and county ordinances and sate laws relating W
OV building construction.and hereby audmrire npreermaloeS of Nis city to enter Open the
Uahnve-mentioned property for inspection purposes
41, (We)agree to saw,indemnify and kap harmless site City of Cupertino against
IE",t rn IiabRiticsjudgments.eosts andexpemes which may to my way.ccrue against said City
V in conuence Of the APPLICANT UNDERSTAN ANranfing D this
WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. nat i t* /
Re-roofs 21(
Signature of Applian✓Conuu ar De
HAZARD US MATERIALS DISCLOSURE Type of Roof
Will de applicant or future building Occup rtsmm or handle hnsrdous material
0rted by the Cupertino Mundicipjo code.Chapter 9.12.cosi the Health and Safety
.Secdan 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
0 Ya a
Will tho applicant or comm building occupant use equipment.,novices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hoModons,I,c.mam e.nts sa Ined by the Bay Area Air Quality Management all new materials for inspection.
District?
0 Ya u
1 have mad Ne hnardnua mamdab Rquimmenm under Chapmr 6.95 of the Caliror-
niaHcolNkSafetyCade.SccdOM25505.25533md23534.1undernmdthoirthc building
does cot cumently haw a tenant,that Itis my respon1b11iry m nodl'y the acupmt err the
reqRmenawhenmanbe prime a enc-m"-war mxA . Signature of Applicant Date
ow ronuNorisdaycnt Date All roof coverings to be Class"B" or better