03060175CITY OF CUPERTINO
INF�ORMATIONN-;
BUILDING DIVISION PERMITCONTRAC,TOR
BUILDING ADDRESS:
19252 MTP=A VISTA
R. DENNIS HOULSBY
PERMIT NO, 03060175
AV
OWNER'S NAME:
FERMITLSUEDATE
RE:
io,
SANITARY O NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 If = I�
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm'hul l am licensed under provisions of Chapter 9 femonomeing
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with Soudan 70)of Division Sof the Il nssand Professions Code.and my hecnse is
W
,
in full force and Cf ML
License Class Lie..
2ND STORY ADDITION-111���
Date Contract.,
ARCHITECTS DECLARATION
Ispu
1 uedcreund my plans shall W stud a public ¢cards
�Ag� E®
Liccnud Prnfcssianai
OWNER-BUILDER DECLARATION
1 bcmny affirm on 1 e1. cacmpt Dun me Contractor's Licenu Lew for the
followingreason.a (Section 7101.5. Business and o Any city or county
at1
V TOp 6
a permit ro construe, alter, i improve de fi mash any nrvcmre
which li h. or
h permit t
its issuance. beapplicantof farsuchmas's Licensle asigned naumcm
pat heir issumd t for such
untto
FL Floor
pursuantOcnis
that he wit pursuant LNC provisionsofCamracandxnulacas
Sq. Area a alOn
Divisionr of the Business Core) on
Professionslation car
with Sectionin
jt)B9ppyt5p
CXCMPd
is kno violation of
Nat io is merefmm and ted aper rev me alleged exemption. Any
that and the
!7 ry `16f
31.5 b l
on 7031.5 by any applicant fora permit subjects the applicant la a civil Penalty of
ei �OCCU ane Type
3.9t� 00 P
not
not more man Rw hundred dollars
Y YP
❑ La sownerof the propcny, my employes withwagsaale(sola compensation,
will Pr fie work and Ne structurera tots Limed or offered wdo mora (Sec. 7000, Business
and Cade: The Convacmn, taw docs not apply lf an owner of
Required Inspections
hiobu i
property whorad who
thereon, and who essuch work himselrar through his
wyess,
own a that In
provilds ded maisuch impmvemwtsin not intendedmplefied for owner,
li
ownemployes,ldinorimprovement
however. the building g or i o the owner-
is sold within one year of mmove
buildcr. will neve the aortico of proving that W did not Wild or improve for purpose of
en prOvin for
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❑ I. a owner of the property am exclusively convening with licensed contractors to
no
conswn the project (Sm. 7044. Business and Professions Code:) The Convacmr's Li-
raw does not apply to an owner of propenY who Wilds or improves thereon. and
who convects for such projects with a convaear(s) licensed pursuant to the Contractor's
Me law.
I am excmpt un rS c. .B&P C far mil rtaon
Date
RKERS 0 ENSATION EC ON
WI
hereby affirm under Penalty of perjury one of the following declaration:
.
El I hale and will maintain a Certificate of Consent to uhf-insure far Workers Campon.
Mind. Is provided for by Section 37M of the Labor Code, for Ne performance of the
work for which this permit is issued.
❑ 1 have and will maintain Workers Compcnsadon Insurance, as rea incd by Section
37W of the labor Cods, for the performance of Ne work far which Nis permit is issued.
'
My Workers Compensation Insurance carrier and Policy number are:
Cartier: Pali, No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Thr Y'elim need rot W compleud if the permit hsrnrone hundred dollars ($100)
or loss.)
1 certify mat i lha performame of in work for whhch this 11.1.1 r issued, 1 spall not
cmployanypc any Non wbjccuo the Workers Componation
laws of Cis
Applilp�
N04 AiplIff( KhN R akhng Nis Cen ficam of Exemption, you should
become eubjeel o Ne woher's ompensadoo provisions of the LIM, Code, you must
foMwilh comply with such Provisions or this permit anal[ W deemed evoked.
CONSTRUCTION LENDING AGENCY
I hemhy -Rirm that thin, is • construction lending agency far me pcHurmamc of
the work far which mil permit is issued (Sec. 3097. Civ, C.)
Lender's Name
lender's Add.
I certify Nat 1 have rtad Nie application and INm Nil the above infurmalion is
conch. I agree tP comply with all city and county ordinances and state laws relating to
Wilding construction, and hereby audtodae mprosenteliws of this city to enter upon the
heline,plgra property far inspection
(Wes) agree to ave, indemnify and keep harmless the City of Cupertino against
which ms
hemline, Of s, costs and Of Oil Pewhhch may in any way ¢crvc against and City
in comequenee of me granting of Nis permit.
APPLICANT UNDER ANDS AND ILL COMPLY WITH ALL NON- POINT
Issued by: Date
SO EG ATI NS.
Re-roofs
/g
igneturta Ire _
Date
HAZARDO ATERIALSDISCLOSURE
Type of Roof
Will Ne applicant n future Wilding occupant sore or handle hazardous material
az defined by d¢ Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Caw. Section 25532(a)7
E] Yes pfa
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding Occupant use equipment ar devices which
p.alitt?
If a roof is installed without first obtaining an inspection, I agree to remove
hazardous air contaminants as defined by Ne Bay Arca Air Quality Management
all new materials for ins ection.
P
❑Ya �Nu
1 have mad the hazardous materials requirements under Chapter 6.95 of me Calirno-
nia Health& SalayCodc, Sectio 255()5.25533 and 25530.1 understand! thatifthe Wilding
does Ml eunemly have a tenant t It u my put hilhy m notify led me.pant of Ne
rtvyi
n1�nCnts mast p r a/fl
Contrite.traC� Date /l
li/
Signature of Applicant Date
All roof covering s to be Class "B" or better
Owner or authanrc
t `y /
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