00090184 CITY OF DIVISION IL , -PERMIT CONTRACTOR INFORMATION:
BUILDING ADDTf0465 FINCH AVENUE JAMES CHRISTIE EI_E TFRTOO"INC00090184
OWNER'S NAM FWEN 1455 EFOXWORTHY A ETLICATION CIgA129/2000
PHONE: W (408) 369-8566 . . SANITARY NO. CONTROL NO.
PARCHITECT/ENGINEER: ILDING PERMIT INFO
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y.A LICENSED CONTRACT'OR'S DECLARATION
I herehyaffirm that Don licensed under provision.of Chum9 Job Description
p P r (commencing
P="q win,section?000)ofDrid„naofineBrom,,and Pro@"Ina,Cmm.nndmylic`0Ce PANEL UPGRADE
mmIfnrto, Ire,
0m a i.i,en,e((ry_ _tO Li,.x�Q
atO 6 U hate Contractor, _
ce LL O ARCI I I'I'ECrS DECLAR ,
to understand my plans hull be used as public ices x "
w of p O Licensed Professional '
OWNER-BUILDER DECLARA9'ION
6.
1 hereby affirm that I am exempt from the Contractor's License Low for the
!'Z 4 fallowing mason.(Section 7031.5,Business and Professions Code:Any city or county
e H❑ which requires aermit w congt
pun,alter,improve,demolish,in repair any stmcture
ce prior m its issuance,also requires the applicant for such Permino file a signed statement -
mmheixlicensed pursuant torocpnwixtnnxofa„ Connaln'sLicense I.e.(Chapter 9 S Ft. Floor Area Vnlut
m.nnmen,ingwintsa,fn,n7000)nruisixion3MhotBtr,inefixnmlPlars"ioaaCode) q' - t6Wtl.77
nr that Im is exempt therefnn,.and Thu laq,for the anogal cxcmpnnn:Any violation -
nl section 7011.5 by any applicant for a pit subjects the applicant to a civil penalty APNgyT&6025, 00Occupancy Type
01,as owner of the progeny,lir myvard"Ices with wages.,their,ole compensation,
It ll do the,wook,and the shumure is not intended or umned fill sale(Si]DW,
Business and Professions Code:'Me Cmannomr's License Low Jrcs not apply to an 305 — FR�gp,red Inspections
owner of property Who builds or improves thereon,and who Jus such nark himself
or through his own employees.provided that inch impowcmcros ae not intended or 307 — I NSUI_AT I ON
oR'cred for sale.If,however,the building or improvement is sold within one year of
mnpm0on(he owner-baddr,oil I he burden of pn,emg that hedw not build nr —
improve f.n punposa of moo, ROOF TEAR OFF
—
601
D 1.as owner nfine property...... xiit"i'sly containing with licensed comrom a,In 602 ROOF PLYWOOD NAIL_
unmet the pmjmt(sec.7(44.Business and Prnre,eionr C.dc:)The Corrosion's 603 — ROOF BATTENS
constructw does ot for pplysuch man ownerofpropenywl,nwBd:sedpurwantes to on. 6V.14 — ROOF IN—F'R CRESS
and who ecoids for wch pmjecb with a cnmmnugsl licensed pursuant no the
Contin axe License Law. _
O 1 on exempt under Sec. ,B&I'C for this rcawn '
Owner Dam /
WORKER'S COMPENSATION DF.CLARA'1'ION
I frothy affirm undci penalty al'perjury one of the li,lluwiol de lmana , /
0 I have and will maintain a Certifcutmof Consem to sult'-Inoue for Worker's
Compensation, as provided or by Section 37M of the Labor Cade, for the // 0
performance of the work for which this permit is issued. O
have and will maintain W'orker's Compensation Insurance,as required by Section
J11N1 of the Labor Cede,for the performance of the luck for which this peram is
issued.My Worker' o penwtion Insurance lamer and Policy number arc.
Cartier: Policy No.:174(07_0 11—11
CERTIFICATION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE _
To,section null not he contplomd II the permit is Iia one hundred dollars
($1 W)or less) -
1 certify that in the performance art the work for which this pcm,it is issued,I
shall not employ any pawn in any fir r so as to become subject to the Worker,'
Compe rtaion Laws of Calimmia.Datcnne
Applicom
NrmCF.TO APPLICANT.ll;after making this Certificate of Exemption.you should
!] Okenme subject o the W'orker's Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCT ION LENDING AGENCY
a 1 hereby affino that permit
iss need IS,, lending agency liar the perfomance
Gz7 of the work for which this permit Ix isancd(Su,109],Civ,r'.1
❑. Q miers Name -
� Z LeIsndcr'a Addles, ,
0 1 ccrify that 1 have read this application and sesta that the ub.we information is
Ea correct.1 agree to comply with all city and county ordinances and.ane E%x relating
0 V m building comnuaion,and hereby vathurim representatives ofthis city mercer upon
y the uh.rve-mentioned property far inspection purposes.
E” d Ove)agree to save,indemnify and keep hamlets the City of Cupertino against 712
} Z) Iiahi Ihics,judgments,cons and expanses which may in any way ream,asnmst said OJ
City an consequence of the srantin I If(his peoma ,
APPLICANT UNDERSTAN N VILL COhnn'LYWITHALL fyfy''0 POI /� 1 �7 f
SOURCE REGULATION, 04 Issued by:, •de /y/� A!L( .f( Date
Signature of Apprcrnticnaallrnctm [[!!//%%D``,n Re-roofs
HAZARDOUS MATERIALS DISCLOSURIi
Will the applicant m finite building occupem nom or handle he noxim,material Type of Roof
ax dented by the Cupertino Munici�p/al Code,Chapter 9.12,and the Health and Safety
'
Clde,Section512(a)?
DYex —
!1�
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hamrdous our contaminants:is defined by nine Bay Area Aar Quality Management
DistrictQ Ys }� all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
have read the Safety
Code, nmmrisH reyuitementa under, 4.1 understand r G.95 of the
if lili,min lleahh&Safety C.vle,5ecait to 2n,that 5511,respo11 1 ityI. that
if the building Jces non currently have n tenant,that itis my responsibility m notify the
ucupem of ge r menuwb must he met ion.,to issuance of a Ceniticme of '
acrpane y Signature of Applicant Date
Owner or aad,o"a ag n `'� -�0 All roof coverings to be Class "B"or better
OFFICE