00080051 CITY OF CUPERTINO PERMIT NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: O
BUILDING ADDRESS:
SANITARI'NO. APPLICATION SU
BM111ALDATE
OWNER'S NAME: 79701 BIXBY DRiA
NIC N
EDONL:
TRNAIiA RONALD T AND TCSHINO TR08/08/2000
ARCHI'T'ECT/ENGINEER IULDENo PERMIT INF
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LICENSED CONTRACTOR'S DECLARATION
Z v: I hereby tfrm that 1 em licensed order rots of Chapter 9(commencing c z—c r a pery si n g Job Description
F=Ctu with Section 7")idDivlaion 3 ofthe Business and Professions Cade,and my license is
infull force and eR t.
Line,
3 LL y ¢ Contractor
a CHITECT'S DECLARATON CHIMNEY REPAIR
v,:9
I u ersmn my plans shall be used as public records
iSC 6
Licensed Pmfessimal
x OWNER-BUR.DER DECLARATION
r 1 hereby affirn that I am exempt from the Cmuranor'a License Law for the ��
following reason.(Section 7031S.Business and Profusions Code:Any city car county
which aquims a pmnit m crmlmcL eher,improve,demolieM1,ar repair any swcture Sq. Ft. Floor Area ' ��'s1ion
Four to its issuance,Aso micros the applicant for such paean w rile a signed statement p7
Net he is licensed pursuant to Ne provisions of Ne Conmageres License taw(Chapter 9 {//
(commencing with Section 7")of DiAsion3 of the Business and Profession.Code)or APN Number Occupancy
Nat he is exempt therefrom may to basis far Ne alleged exemption.Any violation of p y Type
Section 7031.5 by any applicant for a pound subjects the applicant o a civil penalty of $1200
not more Nan five hundred dollars(3500).
❑I,aaawerafthepdopery,mmremployeeawiNwageaaaNeir.alecampena.ann. Required Inspections
will dothework,aods: s o Core innotis License
Law
does
apply to an over of 369019044. 0101
and Professions Codec:The unproven
nbacwr's License law docs Trot want
hi s if owner h
property,who builds or iaided 0 1 rush i and who Jas such work himself or read for
his own employees,provided Net such impmvemenm em nen intended m oHcmd for
We.If,however,the building or improvement is sold within one year ofcompletion,the 101 — FOUNDATION
owner-builder will have the burden of proving that he did not build or improve for pur-
poscifide.). 312 — CHIMNEY REBAR & STRAPS
El 1,as owner of the property,roes exclusively combined-,with licensed contractors to
cn-awn the Forms(Sec.7W.Business.ad Prefeasions Cade:)The Canbanms Li- 514 — FINAL PUBLIC WORKS
cense law does not apply to an owner of property who bunds or improver memon,and
who contracts for such projmu with a connacwrfs)licensed pursuant to the Conbacmr s
License Law.
lamexemptutder Sec. ,B&PCfmrmi,m..
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury,one of the following declarmion,
❑Iheve end will maintain aCertifcam of Consenuo ul6insurc for Worker'sCompen-
Win,as pmvided for by Section 3700 of the Labor Cade,for the performance of the
work for which this permit is issued,
❑I have and will maintain WOrkefs Compensation Insurance,as required by Section
37M of the Labor Cade,for the petformantt of the work for which this permit is issued.
My Worker's Compensation Insurance currier end Policy nomRr art:
Carden Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This ccom need not he completed ifthe permit is formmc horsiest Jolters($100)
or less.)
Inniifymatinmeperformanceoftheworkmwin Nigpermitismosi.ishall
not employ any pe n an manner mhnhien w the Worketry Compcn-
satis.Lawayy elifo G (7 CJ
Appiicen /�
NOTICE{O �T: f making Nis Certifcam of Escmpuun,you should
Mcome subjen m Ne Warkcr's Compensation provisions of the Lehor Cade,you must
forthwith rnmply with such provisions or Nis pemir shall tK seemed revoked.
CONSTRUCTION LENDING AGENCY
Q k for whaRrtn that Nem issued(wedon len ding agency fanhe peRomunce of
Le work for which this permit is issued(s¢.3097,Civ CJ
a Lender's Name
lendcrAddress
I
W 0 certify that 1 have read this y and coup and smm that above information is
6t comer.l agree to comply with all city and county mannans of and stain laws relating e
5 Z
building farebyauthonureoses. Liver of mis city to enter upon the
V 0 above-mentioned property find inspection keep ha.
W F (we)aims to save,indemnify and keep M1ay in an the City ri Cupertino against
C4 li e...cs,judgmfm me
ng eepenses which may in any way mcrve against said City
'r W in<onnequence of the granting of this permit.
F Or APPLICAN S NDSANDWILLC YWITIIALLNONPOINT
N SWR V . EGUI S.t Q
srgnatuAPPlicenU tractUDat
H ARD S MATERIALS DISCLOSURE
Will the applicant or future building nalmnatsmre or handle haasNous mannan Re-roofs
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Code,Section x5532(.)7 Type of Roof
❑Yes No
Wi 11 the applicant or future building occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
emit bavMous air cmosedimm.as defied by the Bay Arne An Quality Management installed. If a roof is installed without first obtaining an inspection
°la m7
❑Yes No I a ree to remove all new materials for inspection. Applicant
❑
I haw bad the haaadrmr materia regniremrs emrider napter695 of me Gah- understands and will comply with all non point source regulations.
fomes Health&Safety Cede,Sections 25505,25533 and 25530.1 understand mat if me
buildsffll cumemly haw a reran at it is my responsibility to minty,the occupant
requireicb must be poor to irsuance ofa Cemf in f soracy.
/?)e Signature of Applicant Date
lwas, nzM " Date
All roof coverings to be Class`B"or better
OFFICE