02010091 BUILDINGDIVISION PERMIT A-vty ixek,ivxllNkVIKA nvly:
BUILDING ADDRESS: PERMIT NO.
20369 CLIFDEN WY 02010091
OWNER'S NAME: APPLICATION SUB DATE
JOHN SIZEMOR 01/23/2002
PHONE: SANITARY NO. CONTROLNO.
�RCHITECT/ENGINEEft: BUILDING PERMIT INFO
U
BLDG ELECT PLUMB MECH
y es I_I i I L _1 L_J
Hz LICENSED CONTRACTOR'S DECLARATION Job Description
i Z—0 1 hereby affirm thin I am licensed under provisions of Chaptn 9(commencing
=tw with Staion7M10)ofDivision 3orth,Busincssand rofesdloneCoda.andelylicense SERVICE UPGRADE.
is in full force arr��dsRcµ
:m.'
wu Licanz osss (�! O Lic.a27
O Dae /_ Contrvnor
ECT'I DO
,6y 1 understand my plana shall be used as pool 0Ns
i p O Lt¢nsetl Professional
' ea OWNER.BUILDER DECLARATION
1 hereby afftztn that I am ceempi from the Contrecwr's License law for the
C z a following reason.(Saban 7031.5,Bainess and ProBssfonsCole:Any city car rouny,
$1500 Z x D which requires a permit to eonswet,alta,impmve,demolish,or.pair any swoon,
atm prior.toiuissuance.aW rtqu'ues0e applkau fasurk pumkto 0leasigrnedstntcment ��if
tBu hgiAlittged pvmr'od tolhe piodsivns dame Creraetofs Lxenx law(Ongar9 '_' a :` 3�75 �t�bA�a' ,t s -
S-Bt !t0 �.-lTV .............. .....
(commencingwith Sation]OOO)of Division3 of the Bnsirassmd Prokssiom Code) Valuation
onhar he B aicmpt ancref re and the basis for the dliged aemptl®.Any violation '
af5emon 0011 Siry myappl¢ant for a permit sobjass Ne epPlkan ro a civil penalty
ofom mom than Ove hundred do1au(S50(l3 :L�1`N NffpbLjtjZ " Occupancy Type
171,as ownecaf de,propmy,ur my amployas with wags a their sole conperaatim, _
will dc-the work:"had the-soon.,,is rot inicni or oRlred for sok"(Scc.7011;
Businisi irN PrIXessionz Calc The Conoator's 13ceme Law does Out apply to am 505 - FINAL lMEDfYp6UQAjtions"
owner of progeny W W builds oc impi on...am who dew such work himself '
or through his own employers provided that such impmvemcnts art not intended or
d icred for ick.Ii-ho vier.the building or improemeini b sold within one year of
mpro'cifor the ounttfeailda will M1ave the When of Proving Nm k d'd rot Wild or' _ -' -
impmve for Wrpose of vle.).
-...._. rotr
the c ❑L a et itha oreject er. oro esdusively cmtrxring with lkemed wntracamo -
:. corutmcL the docs
net
e(Ser.'1019,owner o and Professions Godea Tla Cant her a 1. " ---
and whlawdocsnesapplyro of owner of propentwho builds ocimgova thermal.
- and who contracts
ssoc a.uch projects with a emusea(sl,lirmsed purvant to Ne' '
Contractors Ucrnse law. /07_ ,..._. _ ._._...-
❑l am ascot radar Sec. B&PCfordnisrtamn
Own
Data
WORKER'S COMPENSATION DECLARATION
\ t hereby affirm undo pemlry of pc jury orrc of the following daleraloa:
1 'ji ❑ 1 Wva and will maintain a Camricne of Cometh In self-inure for Worker's
. Comparuants, u poi fe, by Saction 3700 of the tabor Code, for the
eaormame of the work for which this permit is issued.
O I hive and will mainuin Worker's Compensation Insurame,as rrquirtd by Sccuon
31W of the Labor Cod,for the pttfonnaae of the, vert for which this Pamir is
iaued.MY Wofkv s Compensation Insurance carrier and Policy number are:
Curia PdicY No_:
.'CERTIFICATION OF EXEMPT ION FROM WORKERS'
COMPENSATION WSl3RANCE,". . :' .• - . . , . .
(SIOBoThi rtes' re
coon ed not be romplead if the mit pttis for we hundred ddwa r s„ „
..1 ramify that in the pefo{merce of the wary for which Nis permlt o iswedI .• ._. .• ..... .. - "'. • ._• ••-.-.
.fall l'nor em toy any perwn ������ppppppy manner so as to become iubjat m the,Workers' t .
Campari {y sof Cddram�Darc
Appliam
NOTICE LIC Nr:IL aaTmokmg thus larnmte of Eromprim.You should -
Z become subjat to the eskers Compcnsatim provisions of Ne labor Cods you must "
O forthwith comply with such poviaond or his perm hs hall k damrd orold. .. .. _ ._.
CONSTRUCTION LENDING AGENCY.
;�.' Ihereby%fiscthe daieissmur(Sec, M7,CwC.I farthc pedormank
of the woN (or xhi<M1 miv permit is issud lSec.309Y,Civ:C.)
GY z lender's Name .... . ._ .
U m
Z Ltler's Address
I anifydron lhazeread Nis epplkatun and nate drat meaWve infamaion is r
Ea eoered.1-gm ac»mply with all mry and manly ordinances and stats lows Mating
U to budding construction.and hardly aumorire tepredehUtives ordinarily mortar upon
y ts3 tis abovemrntioned prepeny for,inspection puryasw.
E.. 0. (Wc)egrenoaava indemnify end k«p hartdcsi the Ciiy of Cupertino against
h liabilities.judgmrnts,coal end apmses wh¢M1 they in any wry accrues egaimt rid
U .Zi City in eonuquence of the gonna'of thispermit
APP CANTUNDER TANDSA\DN"LLCOMPLY'WrMALI.SON:PCil.NI 1 .
DU CEREGULA WS. "' Issued by: Date _
"more App manVCnntractar ' - - Dae Re-roofs
HAZARDOUS MATg croup DISCLOSURE
Will ehe a Cups or fMuni ipil Coote ufafer 9.1 or handle Hoardan Safer l Type of Roof
azdeWed by th<Cuprnino Municipal Cotle.Cfup«r 9.12.and the HeilJr and Safety " ' - - rZ3 _ OZ
Code,Section 25532(a)' -
❑Yei
All roofs shall be.inspected prior to.any roofing-material being installed.
Will the app-inncarn-1 failure Wnamg by die ay Am,Aircredita or Mmes which If a roof is installed without first obtaining an inspection,'I'agree to.rernove
emit hazasdom air conmminanw as hfiad by the Bay Arca AirQmlitY Maiagemmt
stn°' all new.ma[erials for.inspection.- Applicant understands and will cam 1 with
ores. ❑Na l all non-poirit source regulations. ply
1 have read do'h mareria3s q or merits undo CWpta ti95'of Ne _
ilifan a Hadch&Snfery Cade,S0niom 25505 25533 and 25539 1 uadcant that
fthlbuldingdoa.nae ntlyhavee tenant,that tis myrtsponsibdity eo notify Ne -
P(01-
All
t of the mquim rats which must be and prior a isuaxe of a Cmihate of orSignature of Applicant Date
raa;grnt roof coverings to be Class"B"or better
OFFICE