02090059 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
18750 BARNHART AVE . JAMES H SMITH 02090059
O M594r9 H SMITH APPLICATION
09/10/2002
PHONE: SANITARY NO. CONTROL NO.
E ce0 o ARCHITEC T-NGINEER: BUILDING PERMIT INFO
F BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
z y I ha,en fail,Inst I ant liamad nnder rchn le,9(eommencin Job Description
p`°"'i°°°° p g OUTSIDE LIGHT/SWITCH (1)
is in Sectiorce and
Division l orthe Business and Pmfcssions Code,anJ my license
agpa< iscefull!lass and cBat.
K e.6 License Class Lic.p
O a V Data Contractor
uaS 3 u ARCHITECT'S DECLARATION
Iu.O S I understansnd my plashall he used as public mcnNx
�to
i i o O Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby aBinn that I am exempt from the Contractor's License Law for the
following recto.(Section]031.5,Business and Professions Coda:Any city orcnumy $200
Y F O which requires a permit m mnslrvn,cher,improve.demolish,nr repair any veucwre
a,is prior to its iaanance,also regwresthe.applicant for such permit t°Bteasigned statement Valuation
s. that hg is licensed pmedau
rothepolvistars of the Contrtnufs License Law(Chapter 9 ,�k,�•]]Ofamg3 t�q
(eommenciny with Secpon lIX)p)ofDivisian3ol the Business and Profeuions Cale). iIA� ��39'd/�U4 L{Qgga; \� til fg 1 ,
or t Section
7031.5
exempt any
applicant
pli anJ the breis hes the cos the
hexemption.Any violation;
-orseecon]031svehundpddollrs(SSW)or a titanniatatne-apprramtnacivil penmtyt 304A RCC7LJ73P ELECTRICAL P y�'P
n4nm mnrcwan five hundred dollars fsSml. PN � OCCI ane e
ID L rs ownc,of the property,o,my employees with wages an their pile cumpenvaion, _
will do she work:and,he nrunurc Is not intended or offered for sale(see.]wa, 505 - FINAL E1�QS31Rd.Ii1P{Iections'
'ftuiiness and Pmfcssions Calc The Contractor's License Law does not apply to an
owner of proper,Who builds or improves thereon,and who does such work himself
or through his own employees.provided that such improvements are not intended or i' y I" a
oRcrcd'for sale If,huweveq the bu Id ng or improvement is sold within one year of - G ,
"completion, iv
the owner-builder will he the burden of proving that he did not build or
�'
improve fur Purpose of sole)
,co Lev. Rh p pent I ne ly t ting CodensH contmn .to'
compact theprosect IS ]to14 Business I eProfessions Code:) ITC improves
Contractors
License1 does nt puck r f property h builds°Imp roma th n,
-.and who-contracts for such.projects.wnh onuanortsl licensed pursuant to the' _ �- - --- - - -
,FnlactorsLic - e,-
;ITpm aSo ,B&PC forthismason
, r u=.
Ste ���� `
\ Ok N6ATJOWDEC...NCATION
.•/ thereby ofrnn under Penaltyperjury
eofone of the following declarations:
r ❑ 1 have and will maintain'a'Cenificam'of Conwrc
Consent to self-infor Worker's
Compensation, as provided for by Section 31W of the Labor Code, for the
perflammmn of the work fur which this permit i,!,Iia i,
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3710 of the Ln°r Cow,for the performance of the work for which this permit is
'issued.My Worker's Compomhtion Insurance carrier and Policy number are:
CI er X04, \ I ^,'Poky No, - s-.
\ �.t .. �. S,`atrt, r
CEKTIhIGAIIONOP ATION INSURANCE-
'(I
NSURANC WORKERS'
.OFIPENSATION INSURANCE• '• � ' _. ,_
C
'(1'his semina Italian,he nanplemd if the permit is patinae hundred dollen
(51000 or less.)
I c,,6 that io the ycrfu,ma ,�f)JI rk.RR which t . p tit is isp ed,l - - -- , 1 r.' ., 14 --
"shall t e Delo'day person In any man7kCrs Ir bee° u,the Wnrkcr
'Gpmpansauo ws of Celllom Dat✓/`'
Aplinta
. N tT 'alit - tilt eol'Exanplion,you should
Q Qbac ICu n a provisions of the labor Code,you must
(ntihw it cmnply with such pmvisinns or this permit shall M JttmN revoked.
- .Nr 'v. '" ' ' CONSTRUCTION LENDING AGENCY I '
ho
rlrrm this themiso issued m. Icndi ngagency for the perfo,monce 1
'�
of the work for Wilton this permit is issue)(Sec.30'1],Cir.C.)
Q� - Lender's Name
� -' --
,aJ Z , der's Address .• 4 r . . . . //s` (`�
V 0 I rody Ihm I have read this application and state that the.above information is V '
QEa cit-t.1 agree t" groply With all city and county sTilm nces and slam taws relating
V utbuilding conswction.and hcrery authorize representatives of this city to enter upon
'>; W the above n amioned property forin.vpsstian p.,.a,.
iL ove)agme le fare.;Indemnifyaad keep hartnleisthe City of Cupettitmit,ins,
Vp liabilities,judgments,costs and expenses which may in any way accrue againm said
U City in ommmuence ofthe gaming of this perms
APPLICANT UNDERSTAN AND WILL COMPI. 'LTH ALL NON POINT' Issued Date
SOURCp P dUL.\T C '/ +a0! Y '
HAEARDOUS MATERIALS DISCLOSURE Re-roofs
Width,applisnni or far..building ocia,emsmre or handle hazardous mmcml Type.of Roof.
as
Coca,
Section
the Cupcninu Municipal Code.Chapter 9.12,and the Health and Safety All rOOf$ $halLbe \ t
ICode.Reedtion 25j32(al? , - -
inspected prior.to any roofing material being installed.. ._....__.
Will theippnaantorfuturebuildmgrcc.pantuseaqu{proem or de,caswhich If a roof is installed without first obtaining an inspection; I'agree fo remove
emit hizard m,au contaminants as defined by the Bay Arca Air Quality Management
Oi...fin n all new materials for inspection. Applicant understands_ and will comply with -
oyes , Nu all non-point source regulations.
1 have read the hazer sus materials requirements order Chapter 6.95 of the
Cnlir°miu Heahh&Safety Code Sechcp,15505,25533 and 25534.1 understand that
The Wilding does not currently have a tenant,that it is myresponsibility torridly the -
eccoun,nrthe tirements wm h mall be me�H r to iss once Ota CeniIII °f
�ccuponiy.'
U—71 Signature of Applicant Date
" Owner d ,n Date All roof coverings to be Class"B" or better
u '
..., I," . .. OFFICE ,