00050168 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
HUH.rnNGAggpJ2el PHAR LAP DR 1'1 � ( PERMIT NO,
�— I[AC..W Inc . ,�,
OWNER'S NOT.CE JANE S TRUSTEE_ APPLICATION SUIT D'1't"
050 168
5
PHONE: SANITARY NO. C 1,
zigg —Z667 JAN JOSE RA qsizA
n-Z ARCH'fEL tENGINEER: BUILDING PERM]r INFO
C
w- RLIyG ELECT PLUMB MECH
y LICENSEUCONtAACfOR'SDECLARATION Job Description
y=C 1 hemby atrium ih:n Ian lieenxed under provision[of Chapmr 9(ennnnfnemg
wish Section](Mr))alDivision 3 of the Boiia,,,and Pn,I cxnions Cmu.endn,liccme
6a niufull!araCand C��ccppt
cn
e, Line
One
iiiu"1 3 a I- Ua J Cnmrna'A _
ARCHITEC'1"S UIiChA A ION
7 u O I understand my planc.hnll he used as public recoNx
;c�asREPAIR CHIMNEY ROOF LINE UP
a 6 Liccuwd I'mdcvxinn'l
OWNER BUILDER[)[:CLARK[ION
wI hereby if,.that 1 am exempt from the Comrvanr's License Law far'he
(=Z f"Ilmving rea.[ou.(Sa'iun 703I.5,Business and Pmfessions Code:Art,oly r coumy
E wh'¢h cerin...it Penni,m cun.anst,alm,,improve Mmol kn or repair any a a,hun
a 3 put t t :. an I. y th ppl' 11 h ve a :'g Jit mens
Iharhe is hoan,idl0mountrumi the pr n: f.heContract L (Chpmr9 Sq. Ft. Floor Area Valuation
(con g b S 76x80) fD T nn E . d 1 f:. Code) $1600
or ihu hes sou lban.l , u,dabass lir Phu, cxenpion.Any violation -
of Section 7031.5 by any appdo
cant rot a per in subjects the applicant to a civil Penalty
nour more than Five hundred dollars(.situ). AP url�jo. 00 Occupancy Type
the
work,,c and
the .or my en:plo l in wld,wore. a cl t sole omSec.7 on.
will ne Il,e work,and the suucmre is Contractor
ctor% d or a Law liar role(Sec.]RW,
owner of and Pode¢ions Gsk:The Cnn%there.[License Law s such n work larnsneed lf
or
offered gh h.I own nutid,however.d Provided hut m,, i:mm�ven¢nu Ire not mounted of
ndrereJ ri,r sale.It.however.We building in n,prn u,IJ wiibin one year of
<ampiniunJhe awnerbuilMr will have the burden of proving that he,did not build or 101 — FOUNDATION
improve for pmp„sc of.sine.).
0 1.us to%Per of the property,am exclusively conumeling with licensed contractors in 312 — CHIMNEY REBAR & STRAPS
anxtmm the pn,jeat(See nus.Bu•Ine5s and Prefe%vion•Code:)Toe Cnmmel"rs 514 — FINAL PUBLIC WORKS
License Law does not apply to an owner of property who builds or improves thereon,
and who ontnted for such projects still a umlmnonb) leensed pursuunr in the
Co uom'uu'x Lieenxe Law. - -
❑I vntexempt under Sec. .B&P C for this reason
Owner Date
WORKER'S COMI'IiNSgT'ION DEChARAT'ION
I hemby allfinader penalty of pc jury rancid the fallowing declarations: /
❑ I have and will stain v Cmtiliczm of 37M o u. Labor for Worker's /
C rfourance of provided for by Section 3]IXI m Inc I�Mr Codc, for the
perfnnnance nl the work liar which this permit is iemavl,
❑1 have and will maintain worker's CampenvJon Insurance,as required by Section O
3700 of the[..No Code,for the wtfiumaa wtt of the work for Which this Permit is
iswtvi.My Workers Conipenxation Insurance carrier and Policy m n 'ax:
Currier: Policy No.:
CERTIFICATION Op EXEMPTION FROM WORKERS'
COMP17NSATION INSURANCE
(This section need out be c"mple ed if the Permit is for one hundred dollars
iS 1 W).1 le",I
I ceNfy that in the Performance of the work for which chis permit Is issued,1
•hall not employ any penin in v1. me mnjen m the Workers.
Campcn[ntion/y of Cal
lfotryy D.manner
Applicant
NO'I'ICI?T 'I�p CAN'' Trnwking Ihu Cenilicmcrad Escmpuon,you should
become subject to the workers Cmnpfn ovum provisions of the L,Iwr,Code,you mus'
Q O mohwilh comply with such none si"ns or this permit shall he deemed revoked.
/ r
Vi CONthemis acoNrmlioDING AGENCY
I hembyakfor,hili h this them is a v..ed(Slee. lending agency for the perfnrmentt
W of the work for which,his permit is isxucd(Sec.309],Civ.C.)
0. Q Lander',Address Q z Lender's AJJres,[
V Q I scally that 1 have mad this application and stale that the aMwc information is
W F. "a"'t.I,gree ,,c.nnply will,III¢ity and row,y mdin,nco and e,am law,reining
Q f,)
to Wildin,c _i f Il, by mull u,,mouPPriv,,o1th:culyt care,upon
F ,T] the dNmt,-..tPamd pro,surt,far in,,Oicanpuryn
S (N )agree to v i odcouni I andkeep h ml.,:the City ofC peon gains'
lin linh lT
ital,orn,.. ..and ev,tow,Much nuay r,Y 'y a"one lgai,.r sad ---
f) �_ City in[unxeyuenu of the g nantngnl lhs pato 1, a��T
S URCAIWULARSLANDSANDWILLCOMPLYWITHALLNON-POINT Issuedby:�e /yti�i M.CG7 Date
Signature of ApplicsnhC"nlmcmr Dam Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will lncapphcantor future building
JJoccupant store orhandle haaurkmammedal Type of Roof
us Code. .1io.2,55320L' Mr lolpol�in .Chapmr 9.12.and the Huvllh and 5ulbty
/
All roofs shall be inspected prior to any roofing material being installed.
Will theu,li,am tar mum barihdmrs and uw"u'Pmem rndcvicax which 11'a roof is installed without first obtaining an inspection, I agree to remove
emilhvmdom air rom:nninants ua def ylhc Buy Arca Air Quality M,nageman
Ionil Ian all new materials for inspection. Applicant understands and will comply with
I °V' "" all non-point source gal ions.
I have mad the hu mdoas mamrinlx requirements under Chapter 6.95 of the
California Health&Safety Code,Semi...25505.25533 and 25534.1 u b,onar Ulan
if the hu'di ing docs nisi currently have a mnunt,Ihm it N my renpmxibility ,,nolify be V
ea,,a d the r,,mo,nu n,wnich nmsi net prim m issuance of a Ccuinmre or
O c1P c
5y Signat r ofApr'icant Date
ache ge 1 1 Ie All roof coverings to be Class `B"or better
OFFICE