05040152 CPPY OE CUPERTINo
BUILDING DIVISION PERMIT :,CONTRACTOR INFORMATION:
R fi:DING ADDRESS: GRANITEROCK CO. PERMIT 1005 40152
7.,0 5 S D • AN A M �7n
TRS NAME: PERMIT ISSUE DATE
GRANITEROCK CO.
PHONE: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
lea,O LICENSED CONTRACTOR'S DECLARATION \���(t � O O
E eherebyaffirmWm1emftheBdunderndpisiomofChount. 9(mmmendng 7obl e ,lp\11 n (ILII] .
nerd
with
Scaion](ri))of Division 3.f NC Business and Professi.m Code.and mylicense is
n mB r➢rte at it if ZZ TI- -INTER. /DEMISING WADS
��? Lieenm lass Lic,t
Fp Dam Comncwr �C M G ^n
'y ARC({ITECTS D[CLARA 1 N 1"I AY v� /UO�
v� I understand my plans shall he umd as public records
JyU
LIeeIISCII PnIfC511nnal nn
Oat lam BUILDER DECLARATION rnnfl (1�1, 1
K a:riO 1 reform affirm that 1 sent exempt from the Cosions,Code:Licensee Law for the I✓U(U LI
yp0 followwhichingreasoa.(Secdirmit t iconitr Businessandmp ve,de rush,orAny cry or county O
m which rcyuircs a permit to construct,alms improve,demolish,.r repair any nleaum
_i< lum 000
he its iss sed immlut my,sins the applicant for moh Concur tWx License L w(Cha mem
x�pte.onam li.nwitpursuan70[sRofDiviomoftheutBmi r'aLiccnmLsw(Chapmr9 Sq. Ft. Floor Area Valuation
(comm is
Section of Division?of the Business and Professionsladon of
Ihm heels exempt tbeefrnm and the basis for Ne alleged exemption.Any violation or
Section 7031.5 by any applicant for a permit subjects the applicant to a civil(mnally of 3 SAPNQ4U4Aicro 0 Occupancy Type
nos mare than five hundrei dollars($500L
1,M Owner Of the property,or my employm with wages ar their sole eompemaden,
will do the work,and th,a auclum is not imendW or offered hostile(SCC.EWt,Business
and Professions Code:The Comracmrs Liecme Law does net apply an an owner or Required Inspections
properly whO builds or improves thereon,and who docs such wort himself or through his
own employees,provided that such improvements are not intended or offered formic.If,
however,the building or improvement issold within one year ofcompleuon,Ne Owner.
huskier will have Our burden of proving that be did not Wild or Improve for purpose of
sale.).
❑1,as owner of fie properly,am exclusively contracting with licensed contractors to
cnnrtmcl the project(sec.7(W4,Business and Professions Code:)The Criumfo is Li
couse Law dries not apply to an owner of property who Wilds or improves thee..,and
with cannot for suc h projects with a eunmaor(s)licensed pursuant o the Contractor's
Lice reLaw.
❑ 1 am exempt under Sec. .B h P C for this..on
Dale
WORKER'S COMPENSATION DECLARATION
I hereby alrum under ritually of perjury one of Ibe following declarations:
I have and will maintain a Cenificam ofConsent to self-insure for Worker's Camden-
wind,as provided for by Section 37M of the Labor Code,for the performance of the
wurk far which this permit is issued.
1 have and will maintain Wurkcrs Compenmtion Insurer.,as required by Section
1000 of fie Labor Code,for the performance of Ute work for which this permit is issued.
My Worker's Coaimmandon Insurance carrier and policy number are:
Caoier:7UQ(CFl Policy rvn.;VJC3N72G670
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nal he complemd Rho permit liberate hundred dollars($100)
n less.)
I certify the in the performance of the work for which this permit is issued,1 shall net
employ any peraon in any manner sO as to become subject'.the Workers Compensation
Laws ofcalifnrhis.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subjces to the Worker's Compenmtion previsions of the Ichor Code,you must
.Jz furlhwi th comply with Such provisions Or this perm it shall M deemed revoked
z O CONSTRUCTION LENDING AGENCY
I-. I herchya(rrrn thal there is a emax fon lendingagmacy for Ne performance of
L7:
he work for which this permit Is issued(Sec.3(191,Civ.C)
W Q Lender's Name
W Lcadcrs Address
az
U C) I certify that 1 have read this application and sure that the above information is
OL comet,I agree to comply with all city and county ordinances and state laws relating to A
pU ahmvcngcotionedon,and for by inspection prpmesentativxs.fthiscitymcnerupnn the
dahovemeeion re pto my,far inspection an purposes. 5
(We)amen to save,indemnify and keep harmless the City of Cupanst against Y
N iliabilities,. ,.cco progrmang expenssmfdhis roil. may in any way accuse amain.mid City
U z APPLICA -(UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUI23
Cri.Q(f)U AT'IONS. /s n,/d_
to C Re-roofs
Si .f Ap caHAZAR O Ouse
HAZARDOUS MATERIALSDISCLOSUREoSURE Type of Roof
w the applism or future building oeeupanutorc or handle hvallous material
cfined by the Cupeninn Municipal Cotk.Chapter 9.13,and the Health and safety
.Section 255320)? All roots shall be inspected prior to any roofing material being installed.
❑yes
Will the applicant nrfumre building amnriant use equipment orJcviccs which If a roof is installed without first obtaining an inspection,I agree to remove
ink h.reardous air contaminants as derined by the Bay Arca Air Quality Management all new materials for inspection.
Dlsnict?
❑Yes <Nu
1 have real the hasardnur materials reyuimmenu utter Chapter 6.95 of the Califon
ria Health alciyCme,Seedons255(15,25533md25534,Iundorandthatifthcbuilding
docs n rrtntly base a mnam,Net it is my rcsponsihillty m notify the.ntpmt of the
myurnyc. ma metpnonoissuan.nfaCenifcatcof�c���/, SignatureofApplicant Date
traps.dyer agent (� Data All roof coverings to be Class "B"or better