00050206 CITY LDI wrESION CONTRACTOR INFORMATION: PERMIT NO.
PERMIT
BUII.DINGADDRESS:556 FALLCREF_K SPRIN C BLOSSOM VALLEY CON
11 QA APPLICATION SUBMrITALDATE
' 00050206
OWNER'S NAME ROBERTS, ,GARY AND LOUIS' 1125 MABURY RD WC CONTROL#
sone:. LDS/31/20010
ARCHIT'ECI7ENCINEER - BULDINO-PERMIT INFO
° (408)993-0766
Z i :. LICENSED CONTRACTOR'S DECLARATION '
O
'4E i hereby Million Nu 1 am licensed under provisions of Chapter 9(commencing Job Description
rc,NFv� .with Sation 7000)ofDisisirn3afthe Business andPmRsai...Cods it my license is
in full force and effect.
< License Class Lhoat
w3 y Date Convector
O¢ ARCHITECT'S DECLARATION
J Iundenwldmyplmsshall lin used aspublic records INSTALL AIR CONDITIONING
�a�as
( d�oo
Li<etucd Professional .
tel OWNER exempt R D the ConTIDN
zG 1 hereby,(Sect that 1 em exempt from the Cosuctre o License taw for the ,
O following tensa#.(Section 7011 5,Bminns and Profeuions Cade:Any city or county
which rcquba a Permit to comment,alter,improve,demolish,or repaid,any svucturc
to its ism.na.Wo me theapplicant rmswb Sq.Ft.Floor Area - Valuation
poor rttoipemdtmBleaaLw(statement
Natheislicenetlpunter.to be of Division
of be eBusiness nd Proewww(C olle) , 1
that he is exe WlWS<m;On700dmebuid,fo30ld¢Bm;Mn ando.A,avi Catl<)of APN Number .. Occupancy Type
Nat he is exempt therefrom end the buil for the alleged exemptlan.Any violation of p y yp
Section 7031.5 by any applicant for a permit subjects be applicant o a civil penalty of 36651023. 00 '
nm mart Nan five hundred dollw
❑ I,aaawnerarNep,aperty.wmyemplaymaw;thwag<authdraiol<wmpeuaion. Required Inspections
will dothe wmk end Nenmcturcis trot intcndedaroffered forsale(Sm. OtO,11moneu +
and Profetsimu Code:The Consomme,Liaise taw does not apply to en owner a
property who builds or improves thermm and who dues such wart himself or through
his own employees,provided dust such imp rw menu art nue intended or offered for
We If.however,Ne building or improvement is sold within one yearn(completion,the 204 — UNDERFLOOR FRAME
owner-builderwill have the burden of preying but he did not build or improve for pur- _
Pa"af"'e') 301 — ROUGH PLUMING
1,as owner of Ne property,un exclusively contracting with licensed commences to
construct beproject(Sm.7Bw,Business until Probations ede:)The Cantmion's 303 — ROUGH MECHANICAL
cense taw docs not apply In an owner of property who build,or improves Nercon,and
who convects fwmch pmjm%with acommounauicensd pursuant to the Cantractons 304 — ROUGH ELECTRICAL
Lieeaaelaw. 505 — FINAL ELECTRICAL
❑IumNi
exempt underSd. ,B&PCfor s taro#
Owner , 'a507 — FINAL PLUMBING
WORKER'S COMPENSATION DECLARATION 508 — FINAL ' MECHANICAL t
I hereby affirm under penalty of perjury oro of the follow;.,declirutiom:
Ihave and will maintain aCeniBeate,orconsrnunself.thsumrorWwkersCompsr- 514 — FINAL_ PUBLIC WORKS
atian.as provided for by Section 3700 of the Labor Cade,for the perfersomm of the
work for which Nis permit is wood.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700af the Labor Code,for the performance athe work for which this permit is Saud.
My Workers Compensation Insurance artier and Policy number ane:
Camec Policy No:
CERTIFICATEOF EXEMPTION FROM WORKERS'
COOMPENSATIONSATIONINSURANCE
(Thin section need not bemmple,difthe Carotin i,forwehertecd dollen($100) '
or Ica.) �B
toy any parnom he I.any..n...I ewotkfoewhons,to permit be Asisissued.I s'Courhall MAY 24 2001
not employ any Canon is any mmner so m to Mame aubjw.ro the Wafkere'Compen- '
cation Laws of Cali(omiu.Dec
Appli
nt
NOTICEafter
NOTICE TCy ct to the
Compensation
Nis Cisions of of Exemption,you u moist - BUILDING
berome subject m the Work<ro Compeor this provisions of the labor Cda you roan - -
' forthwith comply with such Provisions or this p<nnit shell be dared evoked.
CONSTRUCTION LENDING AGENCY
Q Ihereby affirm that therm is a construction lending a,ency for the perfu.of
WI ^the wwk far which Nis permit is issud(Sw.3097,Civ.CJ -
a Lander',Name -
lenders Addrtu
Cat 0 1 cense the I have read this application and sue thet the above infmmatito
�+ building
l agree to comply with all city ti county ordinances ad cue laws relating uothe Z bbov.-ncoionned ro and hercbyambedu rtprcarnwivu of this city to enter upon Ne
ebovame(We)
propene for impce0an puryotha
W F., (We)agmen to,ave.Indemnify and kap harmless Ne City of Cupertino id City
V
in
segjudgmentse cmusand expenses which may in my way wane ager##said City
} Ow mPPLICANTe of Nrhe grantingof this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON�POINT
Signamrt of Applicar Contna
ctorr fes^^Jl1 to
HAZARDOUS MATERIALS DISCLOSURE t
Will the applicant or future building occupant Hort or handle haradaua meerial Re-roofs
as,defined by the Cupertino Municipal Cdc,Chapter 9.12,and the Hea1N and Safety
Coda.Se<rmn 23532(.)7 Type of Roof
❑Yes ON.
Will the applicant or future budding wcapmt use equipment or devices which All roofs shall be inspeeted'prior to any roofing material being
emit hazardous ah comemina is as dMnd by be Bay Arca Ah Quality Management installed. If a roof is installed without first obtaining an.inspection
lop """❑Yu 0N la ree to remove all new materials for inspection. Applicant
I have sad Ne hazmdwsmaterial.rtquirtmems under Chapter 6.95 of Ne Cali. un erstands and will comply with all non point source regulations.
forme Health At Safety Cade,Sections 25505,25533 and 25530.1 understand that if the '
building does not currently hove a tenant,Na it is my responsibility to notify be wcopanr
of the requvemorts which must he met prior m issuance of a Certificate of Occupancy.
Signature of Applicant Date
Owner or authorizd agent Date
All roof coverings to be Class"B"or better
OFFICE