04090260 (2) CITY OF CUPERTINO ' ''°
BUILDING DIVISION PERMIT CONTRACTOR NF'ORMA.TTON t:
BUILDING ADDRESS: ""'904
"NOO4 0 9 02 6 0
199-IF R77,KMAN PT.
OWNER'S NAME: PERMIT MUE DATE
JEAN LIVINGSTON
E:
SANITARY NO. CONTROL N0. '
ARCHITECI7ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
_Op
LICENSED CONTRACTOWS DECLARATION Job
=V 1 thereby affirm that 1 sinlimrauC under provisions of CbaPms 9(Commencing
MO Scotian 78110)of Division 3 of the Business and Professions Code.no my license is fertNALED
n w in full fame and effect t
j z License Clear Lie.# 8 FENCE OCT�p
Dow Contractor
DEL L. 2004
F ARCHITECTS DECUBATION
o I understand my plans shall on used v public reenNs
�yU ligap
Licensed Professional
� A I A ®�Ielq II
.�a5 OWNER-BUILDER DECLARATION ' p�(D NN®m
Z 1 smhy alRw that 11. exempt from ton Cssions Co a:An C law for the
0 0 which ng mason.(SCNon Ifo construct.
Business and Professions Coda:Any city s county
$ which requirea a permit it)m ennala4 alter,improve.demolish,m repair any structure
prior N its issuance,also mqn due the applicant for such permit to Ole se Law(Chapter
hb< (that comma lianscJpursuant taH)ofDiviovo(ft oftheBrtcahllmmclaw(ChaPter9 Sq.F[. Floor Area Valuation
m�$ (cot ho Is amp, omfSeetiorm add the
Divisionr of NC egad ex.and Proficaton.Ad,nvi GMc)or
— ]het he u exempt Nertlrom antl Ne baso fm the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects On applicant to a civil penalty of 314flyA Nilr63erO0 Occupancy Type
not more On five hundred dollars(MI.
❑Lsaowrvrk.Neemperry,ormnatiooyworoff rorsgcraleeo .Buinm,
add Pr Ne work and Nenwnpre is not s Limen aLaw do Torok(Sec.7001,Bvinw
pro ertywh obu Code:The Coronations caul law does not apply lf an owner is Required Inspections
properlywhobuildsoded rest
Hereon,andwho manoti intended
his
own a howeves.me Wilding
ip ing or i Nat such cat is improvements art not our ofo oroRered fin ele.lf.
Wilder Ne Wildingurimprovementissoldwithinone year of Improve
efor He owe of
Wilder will hese Ne burden of Proving that on did nm Wild or improve for purpose of
akJ.
1,a owner of Ion property am exclusively emvacting with limned convenors to
co wet Ne project(Sec.7044.Business and Profcsdov Cade:)The Contranori Li .
cove Law docs not apply in in owner of pmmoy who Wilds or improves Merton,and .
who convects for such projects with a conlrutor(s)limnsed pursuant N the Convenors
License taw.
❑1 xempt under See ,B APC far is
am 7
WORKER'S covfpNsArffik DECLARATION
hereby affirm under penalty of perjury one of the following decimations:
love and will maintain eCeNficate of Covent tp self-ivum for Wofkcrs Camden.
stoma.as provided for by Section 3700 of the Labor Code,for Ne performance oldie
work for which this permit is issued.
I have and will maintain Workers Compensation Insurance,as included by Section
3700 of Ne labor Cok.for the performance of On wok for which this permit is issued. '
My Workers Compenstion Insuave carom and Policy number are
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This secbm need union completed lithe permit is for one hundred dollars($100)
in leis.)
1 sonify Nn in the performance of the work for which this Permit's tuned,1 shall not
employ any parson in my manmra as an become subject in the Workers Compensation
Laws orcalif nnia.Data
Applicant
NOTICE TO APPLICANT:If,after making this CenlBcate of Exemption.you should
became subject in the Wohrr's Compensation provisions of the Labor Cock,you mum
0z foMwilh comply with such provisions or this permit shall W deemed revoked.
z CONSTRUCTION LENDING AGENCY
(-+ I hereby affirm Nal there is a convection lending agency for NC Performance of
!Yi the work for which this Pewit is issued(Sm.309'1,Cih,C.)
1 Lcndcrs Name,
=z Lcmim'.Md.
U Q I comfy that I have read this application and mate that the above Infnmlation is
f' correct I agree to comply with all city and county oNlwmes and state laws relating in
0 U Wilding eonswction.and hereby authors representatives of this city to enter upon Ne,
Y'a above mentioned property fm impaction purposes.
(We)agree to ave,indemnify and keep humku On City of Canno n.against
rvFw
liabilities,judgments,costs and expenses which may in any way accrue against War City
Uv7, 'ncommFicnccofthegrantingof ispewit.
^ AJ'PLICANT UNDERSTAN AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
P�O�R�REGULATIONS
Re roofs
al c fApplicantiContractar ate
HAZARDOUS MATER] IS DISCLOSURE Type of Roof
ill dm applicant or future Wilding=open,store or handle ha enhous material
as defined by the Cupenino Municipal Code.Chapter 9.13,and the Health and Safety
Code,S yed 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
Yu 00 Nu
Will Ne applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t havardoes air connotations defined by the Bay Area Air Quality Management all new materials for inspection.
¢vin? ``'/a`I
Yes
1 have mad He hzaardous materials requirements under Chip4r6.95oflhe Califon
nim Health A SafelyCode,Sections 25415,35533 and 25534.1 undersand Nal if dm building
d non cummly hmx a cat Not it is my raaponsiM1ility N notify the occupant or dm
ai mtsnwhich I alpriora I Cenienaneor pea Signature of Applicant Date
37 at All roof coverings to be Class 'B"or better
Ow cruraulhoriandagcnr Dam