08040003 CITY OF CUPERTINO s= r� '�"�€�
BUILDING DIVISION iA
PERMIT ,�£GUNTRA�pRjTN,I<�.,U as 7.'I1�`
Bl➢L�INO,pIW'TbTTON PARK PL ENGINEERED SOIL REPAIRS, PERMIT840003
OWNEWS
N/AME: iNe.S U PERMIT ISSUE DAIS
FIGONE CHARLENE L AND FRANK J 1267 SPRINGBROOK RD 04/02/2008
ONE: SANITARY NO. CONTROL NO.
(925) 210-2150
ARCHTIECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uoo LICENSED CONTRACTOR'S DECLARATION I Job Description
1 Mrmy affirm Nn 1 am licensee under provisions of Chapter 9(commencing P
withsectiam 70M)o ivsaio of Ne Busines, it 6fa '. a .art �y rceMnla INSTL ADJUSTBL SCREW JKS FOR FNDTN RE—LEVELING
^�N in full fame erwc (� '
y y�3 Wconse Lu.g
a, Deu ConlreMr
ARCHITECTS OFA RA ON
Q I understand my plans shell be Wed as public memdr
DyU
hc Licensed Professional
t„5OWNER-BUILDER DECLARATION
f I hereby alErm
that T am exempt from the Contractors License Law for 0e
O O following reason.(Section 70313,Business and Professirm Code:Any city or county
I E which requires a permit W construct,shun improve,demolish,or repair any su tectum
to prior to its boom=,also requires the applicant forsuch permit to rile a signed statement
g e that he is licensed pursuant to the pmvlses,ofthe conkaemrausWeLaw chapter 9 Sq.Ft.Floor Area $4200 Valuation
q (commencing with Secdon 7000)of Division 3 of We Business and Profession.Code)or
f R$E Nu he k;exempt therefrom and the basis for the alleged eumpdon.Any vioiad'on of
Section 7031.5 by any applicant for a permit subjects the applicant in a civil penalty ofNumber O
not mom Nan five hundred dollars ISM 37535028!�� GGU anC P y'l�yPe
❑I,uownerofthepropmty,wmyemploymwiNwaguudte4mucompenudon,
wBTdo thework,and Restructure,lsnotimendeearoneree formic(Sec.7Daa,11hWinesa Required Inspections
and Profeuiarta Como
Crude;The Commoner Liam Law dtou ns
Was t apply an owner of Q P
property,who Wildaarimpmws damen,anewha doesauchworkhi ax1f urthtough his
mum employes,pretided distance,Impoverishes are not intended oroRered fnssale.It.
however,We building or improvement is mid within ane year of completion,the owner-
builder will e,ne We burdan of proving Nat W did not build or Improve for purpose of
tele.).
❑1,u owner of the property,am exclusively contracting with licensed convectors to
construct the pmjecl(See.7004,Business and Profauions Code:)The Commenea U. .,
came law does not apply to an owner of property who builds or Improves thereon,sed,
who contracts for such projects wide a contractor(s)licensed pursuant to die Conmetoes
Lie..Law.
❑I am exempt under Sec ,B k P C for this mason
Owner Data
WORKER'S COMPENSATLON DECLARATION
I hereby arfim under penalty of perjury one of dm fallowing declarations:
haw and will maintain a Certificate ofComentto self-Insure for-WurkeesCompen-
,as provided for by Section 3700 of the Ube,Code.for the performance of the
h for which this permit is issued.
❑1 have and will maintain Wmrkee.Compensation insuranm,u required by Section
3700 of the Labor Code.for We performance of the work for which this Forest B issued. '
My We, C asation Inumme cursor and Policy num cr O
Grrier �rn L^ Policy No.:�
CERTIFICATE OF EXEMPTION FROM W RKERS'
COMPENSATION INSURANCE
(Ihgsection teed tot be completed lithe permit is future hundred dollars(SIM)
or less,)
I ceni(y that in We performance of We work fur which fair Permit Is issued.I shall not
employ any person in my mmnerm as in become subject to the Workers Compensation
Laws of Califerms.Data
Applicant
NOTICE TO APPLICANT IL after making this Certificate of Exemption,you should
Weems subject in the Workers Compensation previsions of We labor Code,you mil
O forthwith comply wide such provisions u this permiL shall le invoked.
oked.
z„ Fr CONSTRUCTION LENDING AGENCY
nom. Ihereb aMm deal there is a commontion lending
Y d agency for the perfurmence of
> the week for which this permit b fared(Sec.3119'1,CW.C.)
W�Q Landers Name
�Z lender,seam••
t.)Q 1 certify that 1 haw rue this application and sum that the show informatiun is
ly
coma 1 agree to comply with all city and county aminase and mote lam totaling to
O V Wilding convection,and hereby authorise representative of Nis city renter upon We
W above-mentioned property for impaction purposes,
Pt (We)agree to saw,indemnify and keep harmless We City of Ctr chino against
to Ilabihites,judgments.casu and expenses which may In any my Woman agalnslaid City
C)Z In cansegiree of the renting of Nis permit. 7q
AP (CANT RSTA WILL COMPLY WI A NO Issued by: Date Ci
UR G6
Re-roofs
urc0WpIib1xf1CL0r Data
HAZARDOUS MA ALS D1 CL uRE Type of Roof
Willy the e Cupertino
m future Wal Co e.Chant rem sur handle Health
material
C de0nee io the Cupertino Municipal Corte.Chapter 9.13.and the Health and Safety
Cents.Section 3ss330>T All roofs shall be inspected prior to any roofing material being installed.
❑Yes Ike
Will dio applicant or future building=open(use c lulpment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
us air contaminanss a defined by die Bay Ana Air Quality Management all new materials for inspection.
es �Nu
c mad din hamrdnumaerials tequinmeou underChapur6.95 ofthe Califor.
Sarm'C Seen=35505,25533 and 25534.1 undermund that(the buildingmnd. a Mems. y responsibility n nod" de cupmt of die
pm P vareearac e a r. Signature of Applicant Date
uth a ager Dnte' All roof coverings to be Class'W'or better