00090107 CITY OF CUPERTINO'
suu.nlNG DIVISION PERMIT, CONTRACTOR INFORMATION:
' BUILDING ADDREIS: �. _ PERMIT NO.
OWNER'S NAME: APPLICATION SUN DATE
CUPERTINO CONSTRUCTION INC000901,07
PHONE: - - - SANITARY NO. CONTROL NO,
I WAY 09/1.8/2100
µ0^I O O ARCHITECTIEI "INFER: - - - BUILDING PERMIT INFO
U BLDG ELECT PLUMP Nil if
LICFNSLDCONTRACIORS DECLARATION 'Job Description
1O� Q 11 byrl nlh'll I' •annul I p fGh'pa )( cog p ' .
1-m w'Ns t ]q)0) fD' 3 flee Bu ,eP of: C le a d ny Reese
Ha 2 sl I III lelfe,.
`
a K s U Licen:e Class L it Q
wa I
0 Date C tAron ,
ARCHITECT'S DECiE LARATI
O I 1 maboared my plans shall be anal a,public awards
� a7 DEMOLITION OF SINGLE• FAM'ILY DWELLING
ado i 0 O 14censed Prnfessinnal
wce OWNER-BUILDER DECLARATION
I—I 1 heachy affirm the Ian exon?,fiom the Civandm nr',License Law far the
Z< following manna(Section 70315,Rainier,and Prnfe,sinns Code.Any oily nr cnumy
f F❑
Which qu pernin, construct, ❑ improve.demolish,h pay surcepture
nam Prol t I. q thepilo rl "hpermit I IIsignal'ttemcn
'let'he ical Presentl top n:'If the Contract.?,Ulloso 1 (Canine,9 Sq. Ft. Floor Area Valuation
(en nc g with Section 70of of�visi ,3 of the Bnna„and Pn Sessions Cable)
or fled he is exmnpt Suacl'ocan and aha basis Entire alleged examplinn.Any violence
of Secsion 70315 by amy'upplicant for a permit sub rot the.,,heart civil lPramlty -
-
,if not mamma,five handled dollars($5oo). - APN Number. Occupancy Type
El 1, of prpery my employees 'th '.n,lh' ,rn.salion,
ill do,h k' ad the am,ble Is n t intended.,ollened for sale(Sec.7044, -
Business and Prafessions Code:The Contractor's Loom,e l,aw does not apply In an Required Inspections
ow r of p ,,cdy Who builds nr improves,h,mom and woo does such work himself n
r through his awn empinyge,.provided thafsneh imPoesanem,are sol intended or, 32628L7,09.' 00 �.
offered for sale.If,howevee the building nnmprovement is sole within one year of _
- mapleren,the wOrenElLnder will have the Imoden of Proving than he did ed band or
Iprove ter marrow nlswe.). ( -
ol,asmemernnhe properly,ant axclo,i,ely cetnrncong vNh licensed caaammors in NO ASSIGNED INSPECTIONS
count met the project(See.70,14,Business end Professions Cade.)The Came.....'. ' .-
License Law does"('[apply to an owner of properly who builds or improves thereon,
and who contrnets for such p jces with a conr:mter(s) licensed poouam to the
Cmdacmr',Lievit Law. _
❑I an,exempt under Sec. ,B&PCFar this reason '
Owner ' Dale
WORKER'S COMPENSATION DECLARATION
• 1 hereby affirm under penuhy of perjury one of thc fnRnwing declaration,:
Elmnmi
I have ad will mn a Certificate(If Consent to self-insi m fnr Worker
Compe 's t
nsation, us pmvideJ fnr by Section 37tH) of the Labor Code, for the
perfeammce of thow k for shi,h0fl,moment,i.suoff
. -
❑I have and will maintain Worker's Compensation a work
as required by ,mit is
3700 . the Labor Gala for pnrfnrmnnce of the work fnr which This permit is
issued.My Worker's Ceanpeamron Insurance enrrier and Policy numb are:
Carrier:_�k0 VC-. Pit Nr: SIJ 99 0/
Carrier •.
CERTIFICATION OFEXF.MPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sbe need nm be completed If the Penni,Is for one hundred dollar '
($100)or lc,sJ .
1 eenify that in the ae,nonetwo of the work fnr which this Permit is issued,I'
,hall no,employ any Person in ally manner m ns}{l fep suhjetl amlhe WorkeM '
Cnm,cror,n Laws of Culiforme,hate % 8
Applicant
NOTICETOAPPLICAfJ'I':I[nRermukingtmi Cl tilicaleaf Exemption,you should _
Obece.,ubjee m IItireWorker's Compensation provisions of the Lohor Code,you must
nmfndhwi,h comply with such provision,or this permit shall be deemed revoked. - -
z .
y
CONSTRUCTION LENDING AGENCY n
a .�i
thereby ff thatb .w, n lc J 6 6 f tl p f
Ord kf h'chl p is. d(S 9 c' C n e -
z Lend N )
Lmad :AJarc:.
I ify
17y 1; read pplcl J t �h 'b f t' r -
�' ra correct.I g w eon,plY tl al a ty Anil ny ori a ncc d stale laws relining a
O V mbuddihgaonnnan
ea .and hmr
erehyurflso mmr,,,enmlive,oftba cry to earn,amen `
W ,he above-mentioned properly or insP,lace parpren,.
Fy ps (We)ngree lesson,indemnify and keep harm)—die City of Comedian agaioo
.. V] liabilities,judgments,coals and expenses which may in any way acerae against said
V City in consequence of the granting of this peorit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS. Issued by: � Date
Signature of Applarmalconnctor - Dam Re-roofs
HAZARDOUS MATERIALS DISCI.OSURE
Will the appEmat ar macre buudmgoccapam Stam nr beadle naardme nmm;A 'Type of Roof .
os definral by the Ci nine MnamBal Cede,Chapter 9.12,and the Hcallh and Safety - -
Cut Semina 25592(0)? -
area 1:1 No All roofs shall'be'inspected prior to any'roofing material being installed.
Will the applicanl or home building necapamase equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
ennil hamnlnux air contaminants as defined by the Buy Area Air Quality Managcmem
Di.trietv all new materials for inspection. Applicant understands and will comply with
Ed Yes ElNo all non-point source regulations.
1 have ram the hamrdou,matertuls ruluirearents under Chapter 6.95 of the
Cabinda Health&Safety Code.Section,25505,25533 and 25534.1 nndersnnd that
ifthebuiddia,do,,not comenlyh a emina,o tul is my rep ..Isfityup manly the
occapeat of the quin me is Which mull hem four to issuancef iGeme C r of
Occupancy Signature of Applicant Date _
Carter :ed agent Dene All.roof•coverings to be Class "B"or better