61138-D-1986 Permit �
PERMITNUMBER ISSUEDBV oa.E APPLICATION FOR BUILDING PERMIT FOR BUILDING INSPECTION CALL 299•2351
pQ ,/ ` p/ SANTA CLARA COUNTY ' � MINIMUM 24 HOURS NOTICE
C. � d y BUILDING INSPECTION DIVISION
70 W. HEDDING ST.,SAN JOSE,CA 95110 7E�.2994351 �� �
ti LAND DEVELOPMENT ENGI I &SURVEVING � � "
. ti '
.IOB ADDR ESS� CLEAPED FOR ISSUANCE BY OPTE
STqEETNIIMBER I�/�.S�a / �/VOL�KG�I • � � INSPECTION RECORD � �
I�` 'wt7NDE'Q �/Clf• � COMPIETEPRIORTOOCC ANC .FO NSPECTIONCALL299-2871 �, rouxonnoru . �
NEqqEST CflO555TflEET ❑ FOFMS
Rp.IMP. 0.E�1FE0 BY DATE
POStOFFICE�CITYI �v / ��V Z�P ��`/ 7 O OWV.FPFR. CLEAREOBV OATE 1. FORMS
J O CLEARE�BY OFTE pO11flNOCONCflETEUNTILTNEM90VEH459EENSIGNFD .
� / ❑OWNER UVP�V"` VHONE Z57.sG93 �, NEATING /
OVCTS
mnawc �E+£.S-p �E��� 7' TRANSPORT ON GENCY a. comvoe. ' �
iIDORE55 COOLING ��
CLENREOFORISSU/NCEBV DATE
�„PEn���Y� . =�o y�iy s. ��AOEAs � ,
�i vHor+e ❑ COMPLETE PRIOF TO OCCUPANC .FO SPECTION CALL 299-2591 1 '
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i COMPLETE
CITV I�p SANIT.DI . O. SEP TK VERMIT N0. FOfl INSPECTION CALI i
l B. SEWER
I 299-GO60 INSYFCT W/TER SERVIGE
�� BUILDING INSPECTION DIV. �
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LOT TPRCT PLAN CHECK NO/.� CIEAR D FOR ISSUANCE BY R.S.OBTE Oy FRESSUFE I
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PEflMITNUMBER OSEOF /� CLEAREDFORISSUANCEBV �ATE
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CERTIFIGTION OF COMP�IANCE OATE �a: +L :[�
NOTE:TOTALFEESEXCLUDE/VPLIC/9LEELECTRICAL,VLUM9ING ' V/W/TION O FEES `+.'� '-� U
AN�MECHANICALVEpMITFEES. �J��'� SEPTIC ") � � PERMITEXPIRATION
T/�K r"' '-+ ? PERMIT EXPIRES IF WORK
COMPLETEBACKOFFIRSTPAGE oo F�AE .. IS NOT STARTED WITHIN
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eep�m m��.���e�or aei�nmem.m�.a�w�a m�.�e.m�w m��e�name om�isi m v�nN q ry �xj :�] 180 DAYS OF PERMIT ISSU-
iny in<onro�m.nm wim eev�i<.b�.sanio.41 ni m.snx.cian Caumy oreln.nw / / cNeCa ~ '
LOUe. Rr G ��:� � ANCE OR 180 DAYS FROM
FORM379183 2 � PEPMR G) � � ''•� U �AST CALLED INSPECTION.
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THIS PERMIT SHALL EXPIRE BY LIMITATION AND BECOME*NULL AND VOID IF WORK IS NOT COMMENCED WITHIN 180 DAYS. � � , ' - ' �' i' " � �9
, ' '
� "REFUND: WHERE�NO PORTION OF THE WORK OR CONSTRUCTION COVERED BY THIS PERMIT HAS BEEN COMMENCED BEFORE THE EXPIRATION DATE HEREOF, REQUESTS
FOR REFUNDS MUST BE MADE IN WRITING TO THE DIRECTOR OF THE BUILDING INSPECTION DIVISION ON OR BEFORE ONE HUNDRED-TWENTY (120) DAYS FROM THE
DATE OF ISSUANCE•OF THIS PERMIT." '� �� �\ � � �
GRADE LINES AS SHOWN ON DRAWING ACCOMPANYING THIS APPLICATION ARE ASSUMED TO BE CORFiECT. IF ACTUAL GRADE LINES ARE NOT THE SAME AS SFIOWN, . . ,
REVISED DRAWINGS SHOWING CORRECT GRADE LINES, CUTS AND FILLS, TOGETHER WITH COMPLETE DETAILS OF RETAINING WALLS AND WALL FOOTINGS REQUIRED,
MUST BE RESUBMITTED TO THIS DIVISION FOR APPROVAL. . �I
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INSPECTOR MUST BE GIVEN MINIMUM 24 HOURS NOTICE FOR EACH INSPECTION. t�� ' ��
` � '
y� !�� ' �. WORKERS'COMPENSATION DECLARA710N ���i . `
' ��� LICENSED CONTRACTORS DECLARATION �
@!� . ,;� � � . I hereby affirm that I have a certificate of consent to self-insure, or a certificate of
' I hereby affirm that I am licensed under provisions of Chapter 9 (Commencing with Workers' Compensation Insurance, or a certified copy thereof (Sec. 38C�0, Lab. C.�.
Section 7000) of Division 3 of the Business and Professions Code, and my license is in
fullkoice and effect. Policy No. Company
� �1 �License Class Lic. Number ❑Certified copy is hereby furnished.
,, ❑Certified copy is filed with the county building inspection department or county �
� Date Contractor department.
�OWNER-BUILDER DECLARATION � Date Applicant {
'� I hereby affirm that I am exempt from the Contractor's License Law for the follow- CERTIFICATE OF EXEMPTION FROM WORKERS'
� ,j ing reason (Sec. 7037.5,Business and Professions Code:Any city or countµwhich requires COMPENSATION INSI�RANCE �
, . � a permit to construct, al4er, improve, demolish, or repair any structure, prior to its issu- permit is for one hundred dollars ($100) '
� ance, also requires the abplicant for such permit to file a signed statement that he is (This section need not be completed if the
/ � licensed pursuaM to thelprovisions of the Contractor's License Law �Chapter 9 (com- or less.)
mencing with Section 7D00) of Division 3 of the Business and Professions Code) or that I certify that in the performance of the work for which this permit is issued, I shall not
�� he is exempt therefrom and the�basis for the alleged exemption. Any violation ot Section employ any person in any manner so as to become subject to the Workers'Compensation
7031.5 by any applicant�for a permit subjects the applicant to a civil penalty of not LawsofCalifornia. � I
; more than five hundred dollars (5500).): � � � � � .� t� � �
O I, as owner of the property, or my employees with wages as their sole compensation, Date Applicant �.
; y� NOTICE TO APPLICANT: If, after making this Certifjcate of Exemption, you should p f�
^ . , will do the work, and the structure is not intended oroffered for sale(Sec. 7044,Business become subject to the Workers' Compensation provisions of the Labor Code, you must
�and Professions Code: The Contractor's License Law does not apply to an owner of -
�+ property who builds or improves thereon, and who does such work himself or through . forthwith comply with such provisions or this permit shall b'e deemed revoked. �
I
� his own employees, provided that such improvements are not intended or offered for sale. CONSTRUCTION LENDING AGENCY 1`�.��, `•, �. ,
If, however, the building or improvement is sold within one year of completion, the � �
. owner-builder will have ihe burden of proving that he did not build or improve for the I hereby affirm that there is a construction lending agency for the performance of '
, ' purpose of sale.l. � the work for which this permit is issued (Sec. 3097, Civ. C.�. � ' �
� � ❑I, as owner of the property, am exclusively contracting with licensed contractors � Lender's Name � '
to construct ;he project (Sec. 7044, Business and Professions Code: The Contractor's \ , .
� License Law does not apply to an owner of property who builds or improves thereon, Lender's Address �
and who contracts for such projects with a contractor(s) licensed pursuant to the Con- � .
tractor's License Law.). '
❑I am exempt under Sec. , B. & P.C.for this reason 1 certify that I have read this application and state that the above information is correct.
�' � I agree to comply with all city and county ordinances and state laws relating to building
� ' � construction,and hereby authorize representatives of this county to enter upon the above-
� � mentioned propgrty for inspection purposes.
• Date Owner ' �
� �
' ' ' ' � Signature of Applicant or Agent Date �
,. �� � �,