06090119 CITY OF CUPERTINO7
BUILDING DIVISION PERMIT
'T1tA0T01 IN'I`'U 2.MA „I3 r
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BUILDING ADDRESS: STEPHEN J GROSS PERMIT NO.00090119
10160 HILLCREST RD
OWNER'S NAME: PERMIT ISSUE DATE
STEPHEN J GROSS
E: SANITARY NO. CONTROL NO.
ARCHMC 7ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
op LICENSED CONTRACTOR'S DECLARATION Job Description
1 I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
P
with Section 701111)of Division 3 of the Business and Profcuium Code.and my license is
t y mrillfoommileffeei. ADDING LANDSCAPE OUTLETS & LIGHTING. ANTI SIPHO
LicenseClass Lie..0
ut VALVE FOR REAR YARD.
po Dau
Dar
ARCHITECTS DECLARATION
I'd 77< I undersand my plans shall be used u public seconds
t6V
Licenced Protocol anal
rer3 OWNER-BUILDER DECLARATION
n
I<E I Wtoby.(firm
that 1 1. exempt Imre the contractors Co :Leon.C Law for my
o o following moon.(Section 71131.3,Business and un,de oli Code:Any city w county
$
which tegvirta a permit re construct alar.improve,cant h Permit t or rtpolr any structure
prior miuiensedprsuntie.also ntutWvisionofthicCohpctor's ccuseLaw(Chtement Valuat$11000
o (com iscingwitpumuamtoNcpmvivision3hcComm�essanimnmledw(Code)or Sq.Ft. Floor Area
25$ that he(commencing 5ecuon,and din basis n7 of Neeged assumpandtion.
Imposeon.my vi Code)or
that o u campy therefrom and the buss for the cia da, Bampton.Any it penalty
of
Sexton 7071.5 by any applicants for a permit rvbjttu the applloanl ou a civil penally of ppN Number Occupancy Type
act mom than five hundred dollar($500). 32616071 . 00
O 1,u owws of Ota pmpmy,m my employes with wages u their mle compenudon,
veld domaw•en-mdmn etmaartunmsLinto Law iia not
apply 0an.ewir of Required Inspections
propand Prtywho bo code Thr Canummrs Uanse oes da set apply lf an owner is q P
own ertywho s,proarimprov chin,and who deenouch wmk himself or through his
ownempleyeea,proWded thatveh improvementsold
within
not ourofdoroedred(w aale.Ir,
however,the building t or improvement u cold within sew your orcanploalm.the awnu-
builder .will have the border,of proving that W did not build or improv for Puryace of
tete.).
1,u owner of the property.am eecluvvcly conning with licensed communist to
nssmn the pr jea ism.7044.Buid...and Pmrens em Coda:)The Cunum tees U.
cetne law dote not apply m an owmr of property who Wilds or improv trustee,and.
hot
o connects for such projects with amnuacml(s)licensed puraunl on tie Conuaetor's
License Law.
❑lam exempt sip See .Bal PC for We on
I Date r O
YORKERS COMPENSATION DECLARATION
I hereby affirm under peulty of perjury orm of the following dttlantons:
C]1 ham and will maintain a Ceriaate of consent m self-inurelis' rke
War9Cwopen-
sadan,as provided per by Section 3700 of that labor Code.for the perfamtmce of this
worst for which thio permit is issued.
❑1 hew and will msinmin Workees Compeeuden Inmranm.u required by Secdon
7700 of die Labor Code.for the performawe of the wort for which Nu permit is leaned.
My Workees Compensation Iltmranee carrier and Polity number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE '
(This section teed tout uncompleted if the Permit is fes one hundred dollen(SIM)
or las.)
1 unify Not in the perfotmanee of the work for which this Permit is Issued,I Null not
employ anYl.rson in any manw�p)Is' =subject m the worken'Cwnpewtan
Laws of CalifomiL Dn. at-
� (.•.•
Applicant
NOTICE TO APPLl .s r mating this Certificate of Exemption,you should
become subject in the Worker's Compensation provisions or the labor Code,you most
O faMwith comply with such provisions or this Permit shall tin domed revoked.
Z
..t.~�. CONSTRUCTION LENDING AGENCY
f^ Thereby affirm that Nen iso cmnuucdnn lending agewy for the perfomtawe of
f2i ,7 Ne wart res which this permit is issued(Sec.3097,civ.C.)
W Q Leadefs Name
0z Lundeen Addrus
U 0 1 certify that I have rad this application and sum that the above informal.is
(y — correct.1 agree in empty with ail city and county ordinances and suss lave totaling to
�U Wilding construction,and hereby authome topmsenutiws of this city to enter urine the
r C shove-mentioned ri.,,ty for inspection ptir Com.
(We)agree to save,indemnify and Imp harmless the City of Cupinim against
iFi V] liabilities.judgnomm.cuu anis .peuea which may in ley way acme agars,sold City
U'Z m consequence of also g.d.&of this permit J /1 J�
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by; Date �f �/ —Ul-
SOURCER LAT - / _
Re-roofs
Signature orKpiflicantContracror Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will to applicant or fun building=put Roto orhandle huardou material
u derued by the Cupertino Municipal Code,Chapter 9.17.and the Health and Safety
Code
S edam 2ss32(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ya �Na
Will despptieamorfumm Wildingaoompant use equlpmmlwdcdna whim If a roof is installed without first obtaining an inspection,l agree to remove
emit hnamna airmnumiants in defined by the Bay Area Air Quality Management all new materials for inspection.
D cR
Co Yes �No
I hive mad also bvntlmts msuriab requirements under Clupun 6.95 ofd.Calif.,
our Health h SafayCWe.Seetiem 25505,25533 and 25534.1 undertund that iflW Wilding
Jess ml Corte a u mi.that it is my respomibility in notify the occupant of the
requirement hie in etpriermv'augpceofaccrtifeauoroccupanry. Signature of Applicant Date
O. madflikeindagooL GG Date' All roof coverings to be Class"B"or better