02030004 TY OF
CI
BUILDING DIIVIISIONNO
LPF:RMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
18283 CHELMSFORD DR. JM CONSTRUCTION 02030004
OWNER'S NAME: APPLICATION SUB DATE
,AlkTOM BANKS 562 DIVISION ST 03/01/2002
r 10NE: (408) 379-9852 SANITARY NO. CONTROL NO.
O o
O'SWARCHITECT&NIGINEER: BUILDING PERMIT INFO
2-6t BLDG ELECT 'PLUMB MECH
y
Z. L—A L-_t
• y i LICENSED CONTRACTOR'S DECLARATION Job Description
i z= I hereby allfrm that Iran licensed and r provisions of Chapter 9(mm'now"g P
yl-cd with Semon (Mxl)hf Division3of the B�,Sip >ana Prnrc,.inn.cnd<,aw my license ADD FLOOR RECEPT.
i; 's in full d.Pita .�" 6
ec x< Li<. xe _ <.. 73
r tiV contct
CHIr SDE A�ECT0
S 1 undemmind my plans shall be used m public rurords
3 Liremetl PrtdeesionN
Nan I..BUILDER DECLARATION
1 macr alihm on I om.Bump,from m.Cessions r i License Law for the
pZ following reason.(Scion 703 1.5.Business and Professions Code:Any city orae my
N O x1 sh q p o t t , Iter,mpmvc,diabolist.t ,a xi any r corm $600
o. ^m .Prh t , also inquires I pp1 aant roe xuch perms t t s g cJ ,Cement _ _ _ l
mots aWp _ gn,mmePm's i rthtContractorse1 en. la (enpter9 1, _ . ''3�'y'� .. � . Valuation
(run 'ng 'rub a ]Ixxo rD " 3 nn li ppm.amp Pmt code) ( 1 'y•j`:
or S ,Section
¢exempt any applicants
li and rbc has far,he alleged eannpno o Am noonday -
^afsec,ion]03Lg by any appliam forapctmit subjects the applicant ton civil penalty a
of not more than five hundred dollars($500). 30�1"N ELECTRICAL " Occupancy Type
❑Les owner of the pmpeny,or my employees wish
"'heir sole compensation, _
will do the work.rad the xwure ctis no,intended or offered for sale(Site.70,14.
V1 R12—TR CA.I
IBminess and Professions Code:The Contractor's License Law does not apply to an 512 — FINAL I_IANBiIedChMections I"
own
cr of,mpeny Who builds or impnrva,meneon.:Od who m:ox xuch work hums<If
or through his own emPloytts.providW ilia such in,proeemnus are nm intend.d or
compI
offend for sale w howuilder a building a burden of prow
improve for the owner-builJer will have me burden ul proving,lin,he din no,twild or '` - "'improve for purpose of sale.).
❑1 ax owner of the prop.,y 'x sivelY co t t g llith licensed contactors to
conswct the pbm.(Sed.]PW Btoine,,and Polk,xican,Code.)The Cnmract is -
License Law does no,apply to an manor of properly who builds or improves the on
and who contracts for such projects ith a c , t rO licensed pursuant,o the. -
Comanols Licome La . J-
❑Iamcx.mptunderSec ;B&P C rur tnisrcason •t : /
Owner Date /1
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
0 1 have and will maintain a Certificate of Consent ,o self.amare far Worker i
Compensation, as provided for by Section 3]0(1 of the Labor CWc, for the
performance of the work for which this gamin is i...id.
❑1 have aW will maintain Worker's ConaNnsaihn Iniumoce,as required by Section
37M of the Labor Code.for he perfmrwnce of the..,it for which this Permit is
wsued.My Worker',Co p f 1 ranee c True and Pol yrobe are
CERTIrtfArION CFEXSA IONIC Rq�S KERS - L ..as• - II ; l i.Y� "i 1,'„ .,1.f :', \.
COMPENSATION INSURANCE. '
(Thfon need not he
($1001 rlcss.) Completed if the p.rmi,is for one hundred dollars .. .,
1 cemfy that in the performance of, w rk f which this perm t roe issued,1 I -
shall nm employperson n maer as to bsubjecteam. b)<ct,o the work<rs'
ns - - -
Compeaihn Ids.,.,wx of California.
nnso Date
- t
NOTICE •
NCE
Z"" V/ • ., TOAP • TI' ft- k Crff Exemption
Z Became subject o the
Worker's'Compensation pn of the Labor CWc.you
u mus,
forthwith mplyesuch Provisions or this Permit shall be deemed resoked.O •1r
-
CONSTRUCTION LENDING AGENCY
hereby nmrm that there is a construction lending all for the performance -
� Q Lente work for which mus permit is issued(Sec.709],Civ.C.) `
� -Lenders Name
Z Isnder's Address -
V 0 1certify that I have read this application and state,hat,he above information is
correct.1 agree to comply with all city and county ordinances and state laws slating
O IJ to building chnarudion,and hereby authorize representatives or this city to enter upon
the above-mentioned imildry for inspection pa,so,tc,
F. 96 (We)agree m save:indemnify and keep formic.the City ofcuperlino against
h liabilities,judgments,costs and expenses which may in any way acome against said
V i City in run cqucnce of the grunting of this pertnit.
,A OR
`TUNDEB \NDS AND WILL COMPLY WITH ALL 'O.N�POI"1'
uR E I ecuun - I NT Issued by: Date
signature afrApplica Contactor 'Care .. Re-roofs
AZARDOUS MATERIALS DISCLOSURE'
' WiIINeappliaaniorfuture buildingoccupaniatom orhandle hazardous canerial Type of Roof ..
Code.Chapter 9.12.said Health and Safety "' "' " - • _ _ ._. . .... _
as - _
c e yt. open un pal -
CWe S a 255t21a) : 1 ( ( .. .. i` . , '.•. .
❑r a oN - All,roofs shal-I be inspected,poor to any roofing,material being installed.
.Lan usaappontami r t c lined <v reequipment o devices which If a roof is installed without first obtaining an inspec[lon, ]'agree to remove
mit hazardous contaminants as defined by rh Bay Area Air Q all,y M nagem t g
"`"" all new materials for inspection. Applicant understands and will comply with
01 ye, RN. P . , PP
511 non-point source regulations.
6 lead the hazardous a.nals q 25533 and
255 Chapter ti 95 d Ne t
Califon a H adu&Of cur Code.Sections 25505.25533 it
and 25574 ilnndersm notify
if the
won m docsnotcunen which nut
ItoLma,it lmyreeponsibili,y to notify Clic
:xcu mil
e4cquire cn which man be mitt poor,a izsuan a of 5 Cenifces of
Doc no
Si nature of A llcant
-OZ B- . .. PP . - Date _
ncroraum nzedag n, Data All roof coverings to be Class "B" or better
OFFICE - t
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