00080038CI TY DON
PERTNO
BUILDING PERMIT CONTRACTOR CONTRACTOR INFORMATION:
BUILDING ADDRESS:
OWNER S NAME. 19701, BIXBY DR
LICENSED CONTRACT'OR'S DECLARATION
firm Nal T sum licensed under provisions of Chapter 9 (commencing
of Division 3 of the Business and Pmfconcns Code, and my license is
full farce
tt se
'con _
rne Contrera err +> wt —vnfL
AR fUTECT'S DECLARATION �—
u�pemend m Ie�ls 1 be herd blit rcwN�
Wccn�r Professiorul
Oer I am exempt
to DECLARATION
1 hertby a(Sero on 1 w erempt s ad the Comr«mh License law for the
following reason (Section 703 LA Business and Pro(de moll h, or Any city or county
which requires a permit m cammhe alder, improve, h Formed t or repair any structure
prior ro its lessee, also m I. to the inions of for such pemdun files signed s hapten t
thus he is (commencing
purswm m Ne of Division
of dw a Business
id Poli Lew (Chapter
tham he
exemitt Section andilof Division3 of the Busiesand RoAny vi Calc) or
Nm he is campy any
and the beers for the alleged exemption, t Any violation of
Section mom by any applicant fora permit' subjects the applicant a civil Penalty of
not mom Nen five hundred dolma (SWI.
L oche wor d the the st nchum my employees d or
wagu as aleinole compensation,
will dote work, and the he Ciro is not intended offeredw do for sale (Sec. o art Business
and property
who
Cale: The ve, dreor'a Liana law does not apply ro if owner of
his O ny wbo builds or improves t such i and who does such work himself or through
his own employees. provided Wt' such improvements em era imrrdN a oRerttl for
We,ILhowever Nebuildinguren of pomeht iesoldwishinaneildori pone for the
her -builder will have the harken of proving that he Aid not buil) or improve for pur-
prsu of sale.).
❑ I. m owner of the properi sus exclusively contracting with licensed connectors to
constru<1 she projecr (See 7044, Business and Professions Cade:) The Commode Li-
cense Law docs not apply to an owner of property *bit builds of improves thereon, and
who amuses for such Proj«a with isconvectud') licensed pursuant m the Comrector's
License Law.
I am exempt' under Sec B& P C for this match
Owner Dam
WORKER'S COMPENSATION DECLARATION
. I hereby affirm under Penally of perjury one of the following declarations:
I have am will maintain a CeniOca¢ of Consent yo mlf-insure for WOM1CYa Compen-
smn ae provided for by S«lion 39W of the Labor Cade, for the f.mums. of the
for which this permit is issued.
wo I have and will maintain Workers Compensation Insurance, as required by Section
39W of Nc Labor Cede, for the pIdortnmce of the work for which this permil is issued.
My
workne tpe uttoo Insurance cam Card Pal YNt[ynumbcrafe��9/�
CERTIFICATE OF EMPION FROM WORKERS'
COMPENSATION INSURANCE
(This s«tino need nor be compleed if the Permit is folone hundred dollar (31 W)
or lusal
1 certify that in the performance of the work for which this permits is iasued, l shall
nor employ any n ,e any roll aygm he o bj«no the Workers' Compen-
rarinnLows
i Dare!/�/—S' 7fN..� /
APWicant ,Iea"I ��Q.�lf Za
NOTICE TO APPLICANT. If, art« king this Certificate of Exemption, you should
hscnme, subject to the Worker's Compensation provisions of Ne Labor Cale, you must
f x"hwit comply wit such provisions in this permit shell be, deenrcd revoked.
IKO TR
0 - - 108/07/2000
Job Description
FROM WOOD SHAKES TO VILLA TILE
Area
CONSTRUCTION LENDING AGENCY
I hereby ifrm that tem is a cormlmaian lending agency fnnhe Performance of
the work for which Nis Permit is wood sec. 3097. Civ. C.)
[.. Lendcer Name
[G i lenders Address
W A I certify that 1 have read this applicalion and these that he ahuve information is
as correct. I agree to comply with all city and county ordinances and state laws relatingin
U O budding consnhchim. and thereby amhonu rprtxhounives of this city m carer upon the
atrove-mentioned property for inspection purposes.
R. F,a. (We) ague to save, indemnify and keep harmless the City of Cupertino aFiddi
C C.7 liabilities,judgments, costs and eaproses which may in any way accrue against aid City
;,. W in comequencut the granting of this Permit.
SNI' UNDERSTANDS Ay)WILLCOMPLY WITH ALI. NON -POINT
S RCE�REK]U ATIONS.
Dole
Sigmmrf ul ApphcaHAZ,si nmor Dare
HAT.ARDOUS MATERIALS DISCLOSURE
Will to applicant or future building occupam store or hadle horadous mamuei Re -roofs
as defined by the Cupertino Municipal Code, Chapter 9.12, sal the Health and Safety
CWgS«don l?5532fa)p Type of Roof
❑Yes C] No
Will the applicant or furore building occupant use equipment or
c onradevices whichen
mit ha oro our air cminents as defined by the Bay Area Air QualityManagemt
District?
t ❑Yes No
_ II have read Ne ha odsws materials requirements under Chapter 6,95 of dm Cali-
fornia Health & Safety Cale, Sections 25505, 25533 and 25534. I understand Nal if the
building de nor enormity have ..most. Na his my, responsibility m ngify to occupant
of Ne requirements Which most tenor prior roc Issueoce Of a Cenifcem of Occupemy.
All roofs shall be inspected prior to any roofing material being
led
instal. If a roof is installed without first obtaining an inspection
I agree to remove all new materials for inspection. Applicant
understands and will comply with all non point source regulations.
Owns err aolholent agent Dare I signature of Applicant
All roof
OFFICE
Date
to be Class "Ba' or better
Required Inspections
35909044.00
305
— FRAME
307
— INSULATION
601
— ROOF TEAR OFF
502
— ROOF PLYWOOD NAIL
603
— ROOF BATTENS
04
— ROOF IN—PROGRESS
CONSTRUCTION LENDING AGENCY
I hereby ifrm that tem is a cormlmaian lending agency fnnhe Performance of
the work for which Nis Permit is wood sec. 3097. Civ. C.)
[.. Lendcer Name
[G i lenders Address
W A I certify that 1 have read this applicalion and these that he ahuve information is
as correct. I agree to comply with all city and county ordinances and state laws relatingin
U O budding consnhchim. and thereby amhonu rprtxhounives of this city m carer upon the
atrove-mentioned property for inspection purposes.
R. F,a. (We) ague to save, indemnify and keep harmless the City of Cupertino aFiddi
C C.7 liabilities,judgments, costs and eaproses which may in any way accrue against aid City
;,. W in comequencut the granting of this Permit.
SNI' UNDERSTANDS Ay)WILLCOMPLY WITH ALI. NON -POINT
S RCE�REK]U ATIONS.
Dole
Sigmmrf ul ApphcaHAZ,si nmor Dare
HAT.ARDOUS MATERIALS DISCLOSURE
Will to applicant or future building occupam store or hadle horadous mamuei Re -roofs
as defined by the Cupertino Municipal Code, Chapter 9.12, sal the Health and Safety
CWgS«don l?5532fa)p Type of Roof
❑Yes C] No
Will the applicant or furore building occupant use equipment or
c onradevices whichen
mit ha oro our air cminents as defined by the Bay Area Air QualityManagemt
District?
t ❑Yes No
_ II have read Ne ha odsws materials requirements under Chapter 6,95 of dm Cali-
fornia Health & Safety Cale, Sections 25505, 25533 and 25534. I understand Nal if the
building de nor enormity have ..most. Na his my, responsibility m ngify to occupant
of Ne requirements Which most tenor prior roc Issueoce Of a Cenifcem of Occupemy.
All roofs shall be inspected prior to any roofing material being
led
instal. If a roof is installed without first obtaining an inspection
I agree to remove all new materials for inspection. Applicant
understands and will comply with all non point source regulations.
Owns err aolholent agent Dare I signature of Applicant
All roof
OFFICE
Date
to be Class "Ba' or better