S 4542CITY OF CUPERTINO "'
'• DIVISION
* * *''
INFORVA IO xBUILDING
N
` "
7fA
BUILDING A1Y,CJGS'• ALDERBROON, LA. -
PERMIT NO.' S 4542
OWNER'S N EL ROGER H AND 'FAITH E
APPUCnnoNSUe A
- -
PHONE: "• '
H'
- -
SANITARY NO. C
ARCHITECT /ENGINEER:
BUILDING PERMIT INFO
' -
•
BLDG a ELECT PLUMB MECH
_
I I .ICBNSEDCOM'RACrOR'SDECLARATION
t
' Job Description '
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 711009ofDivi,c[on Suf the Boston,, and Pmlesuinne Code, undmy beirea
_ -
iafullforceandefcct.
License Class _ Lic, p
Data ConWetar.
. - -
. ARCH]I'EC9 'S DECLARA"I'[ON
1 torde,ond it ;,l ;,lar, hall be used as public records ..
- • ' • �,
to
REPAIR /TERMITE` WORK, REPLACE ELECTRICAL
Licensed P f tonal
j OWNER - BUILDER DECLARATION
.�
1 hereby 'afum that 1 am exempt from the'Contn¢tur's Ltccnse Law, for the
-
Ullow'tg ressan Section 70315. Busin d Pmt ifs Cdr: A y thy onourty,
� � � '
which requires a permit in .tr a, alter, unprove. thanolisli, (it repair any structure
- p„ - r
prior to its issuance, alai requims the appheant for such recent m file a vlgned statement
-Sq. Ft. Floor Area .
- Valuation
that he is licensed p : t to ilia provisions of the Contractors LicarNa L (Chapter9
(call tech, with Section 7W0) fDivision ' 3 of the U drobotism, Code)
•.
t
15000
or that he is exempt therafro n and the bass for the allcgcd exemption. n ry solution
-
of Section 7031.5 by any applicant 6, a permit subjects the applicant to a civil penalty
• of pa,;mere man five hundred dollars (x500).
-il -. APJi��TC }u b�7elrq 00
- _ ,Occupancy Type -
❑i,uownerefthapmpeny,c,,i n to titwa then, solecour ensation,
Ye v Yeeswi ,cads p
-
- -
Required Inspections
will the work, the re is not intended olf for sno't 7W 4d ,
e ne Professions Coca fi C t r . L en Line see. net app] y t m
(Set cny
f ty Id. p t J 1 kit If
'
or through e Fll y provided tit r: p e t d J
t
aft le i sa IF h the building or jouporkenicat is sold wu,fi
'and
completion, the builder will have tl - br rdctuf proving t �th di d tb'ld err
,tp [or rat f sale.).
- -
-
C? —.FOUNDATION
41
�do
tom_ �wnts of the P �peuy am c.eno,ody contracting win 1' licensed contractors to
2 - 'PIERS - -
coutruct the protect (See. 7044. Business and Professions Cacti) The Contractor's
• 103 UFER
License Law does not apply to an owner of property who builds or iinpreves thereon,
and who commas in each prejecus with a cLaramoas) licensed ponsuand to me
- -
.. ,
104 REBAR" ". I i
Gtmraeer'e U"n's Law
❑Iam exempt under See. B & P C for this reason
*
- -
_ .,105 —.- ANCHOR 'BOLTS
wnnG
WORI�OMPENsnrIONDECLARA�N —
106 — SEWER A• WATER
I hereby affirm finder pemdlyef ,at, erne of the Following deemrafionss'_.,
202 — UNDERFLOOR PLUMBING
El I heve :ma will ttaimaim a Crmfi.ta of Cm,seat to self - insure for Werkere
203 — • UNDERFLOOR MECHANICAL
Compensation, us provided for by Section 9700 of the Labor Code, for the
- —
t;. 204 UNDERFLOOR' FRAME
perfmrnanca enhe work ru,which rhispc,mit is i....c. ,.
:.
205' — UNDERFLOOR INSULATION
❑ i heve and will mountain Workers Compensators Insurance, as to by Section
3700 of he Labor Code, In, me plu m atanee or asp work ro, whieh this pennn is
',,sued
301 ROUGH PLUMBING
My Workers Compensation Insurance carrier; and Policy number are:
- -
1302
�
" —'TUB & OR SHOWER
Carrier: EXEMPTION FROM WORKERS',
- CERTIFICATION of AI ION
303 — ROUGH MECHANICAL
INS
COMPENSA'riON INSURANCE
'304 ROUGH ELECTRICAL
hdad duars
($100)... less,) .
-
.305 '— FRAME - — •.
1 certify that in tire periourremce of wart fo, which twa permit is Issued, 1
I 306 —^ HOLDOWNS - -
,hall net employ any person In any ..tanner so as to become tables, to the Warkc,e'
Compensatlna Laws of Coldmnla, Date
- 307 INSULATION
:Applicant - -
NOTICETOAPPLICANT, If, after making this Certificate of Exemption, you should'.
306— SHEETROCK
become subject to the Worker's Compensation provisions of the LaborCede, you must
' forthwith comply with such ptomaces erthis perch shall be deemed revoked.
309 — EXTERIOR' LATH - - -
CONSTRUC'1' ION LENDING ACENCY -
-' 31.0 -• INTERI'OR LATH"
I hereby allure that there is a consin action canfing agency for the performance
-
311 — SCRATCH rCORT
of the work for which this pcmtit is issued (See. 3097, Cie, C.)
- ,.
harders Name
Lender's Address
3 f3 — ROOF NAIL
'" '
Icerafythat l have read th is application and state that the above information is
,
,' 501 — FINAL ELECTRICAL ENERGY
enrela. I agree to comply with all city and county ordinances and state law. relating
If, building construed on, and hereby tuthunae in,se,ntwives of this city to enter upon
50? .:— FINAL MAI_ � PLUMBING MG ENERGY "
-
meemt( We) areeeosave,nYfnrifyandkepharmle
(We) agree to prop, property for ins end keep harmless the City of Cupeninbugainst
503. — FINAL MECHANICAL' ENERGY
liabilities, judgmentx, costs and expenses which may in ;my way resume against said
504 t FINAL' BUILDING. ENERGY
'
City in consequcnet ad the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON -POINT
- .
Assued by: 505 -' FINA I CIR rA Date
Y• L
SOUR�aCGaa��¢EGULATIOty'S.n �'' -rIOO
"`iiZEZ
iJil,;r (mow'^
Signature Appl cant /Contactor Pare
— _
Re -roar -• '
HAZARDOUS MATERIALS DISCLOSURE
C'
�., FINAL, PLUMBING
�' 507., nl�l
W,11 "he opFllicu m o, home htildl g u pan shoo or handle h a wine material`
t507,
Type Of Roof
as defined by theCepeourat Municipal Code, Chapter9.12, and the Health and Safety
508 — FINAL' MECHANICAL
Cede, Section 25532(a)7
_
'All roofs shah569nspedreIlI0 16i tC�I W ing material being installed.
Will t1 pviu t , Lama b ldi g n t as, en,mr,unce, devices wh cif
If a roof is inodlorl witjmbphOot oPKj 4*gglTN(g;pection; I agree to remove
mrh rd ircot a ,deindbyth Bay A' Quality Mne,anent
lit mi t -
�' °ve" -
all new mateitlis4br —inype�AL 4Mjyerj6ncW fjW� and will comply with, ...
all non -point source regulations.:,
I have ad (lie ereenewo, r I q t, under Chapter 6.95 of the
Cul f H Ith &S f tyC d S r 25505 25533 rial .1 andeastradmat
if tl building d t' tlyl t tth rl. y p :'b I'tyt t[y he
S�a (��QC2
111
certain f tit iequ cartel, witch rut be at ,I m issuance of a Cemficate of
-
ceapancy ' -
Ignature of Applicant " 'Date '
��i 5 /ay /o 0
- All roof coverings to be Class sB" or better .
Date
-
1. OFFICE