01080090 CUP
RTINO
CITY BUILDING
c DIIV�IISSIONPIERMI'Il' CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
7592 HOLLANDERRY PL FARKAS STANLEY R AND HIL RY J01080090
APPLICATION SUB
TOW STANLEY R AND HILLARY J 08/20/200E1
PHONE: SANITARY NO. CONTROL NO.
q 0 ARCHITEC rfiNGINEER: BUILDING PERMIT INFO
Lk'V BLDG ELECT PLUMB MECH
�< 1=J — t LJ I-. I
LICENSED CONTRACTOR'S DECLARATION
i 5„I Job Description
ction7M)oI hereby fUmion3I am ofenmdundessadsiofsof sion,Cde.and.1It.r 9 .g ADD OUTLETS .
F9(- with full force and effDisect. on3or the Business end Pmfeuions Code.and.1 It...
<m ce is in full Ione and eRcct.
i s w Date Class Lira.p
it a
Date S D ECLA
ARCHITECT'S DECLARATION
1 understand my plans shall be used as public records
i oLicensed Professional
nOWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License law for the $150
F z a following reason.(Section 7031.5.Business and Professions Cade:Any city or county
,, which mcmm,s n permit m construe,.almaimprove.demolish,or mini,any smusture
wa m Prior to its-[trounce,also reaquim.s the applicant fsuch farmer filea signed ornament -- - -
a3
'hat he licensed pursuant to the previsions ofth Contractor,;License Law(Chapter 9
(cm,nourem,with Section-7ooly of Division l of the Business d Prefewilum,Cale) 3 6%Q�1n 0�Fd90r Fcoat Valuation
or that he is exempt therefrom and the basis for the alleged exemp,ion.'Any violation
of Section 7031.5 by or,applicant for a permit subjects the oPplicsm no a civil peunity
l of not mom loan five hundred doll.(S500). 3 0 4 APNMSZ AM ELECTRIAli'-t ` • Occupancy Type
❑1,as owner of the property,or my employees with wages as their pule compensation,
will do work,and the structure isnot'ear's License
Law for sok(Sec.70,114; 505 — FINAL ELIK03Md UAf@ctions` - -
owner of and property Who
Cale:The Cmnmaorthereon.and w law docs oro apply to nlf
srwnc
r of his ow Who lotees or oidedts atsuchand who does such work himself
or through his own employees,provided that such impmvemems,re not]mended or
"1'ofrered for WE If.er - th building p- t Id uh n o year of -
improvefarpthe nwn b Id will etheh d Ip gbatl JJ thu ld or
improve tar pamDae r I 1
inaso)5struct
wthe proset(See.
7Baa Business d Professions Gd:)The Commuter's
omut snerohe.pream contracting with Inec mm
License Law does notapply t ej owner (property whbuilds improvesthemon,
and-who.contracts.forsuch prejents with a c ntroctntslicensed pom to the
__ ._
Comradors LicenseLana_ .
W
❑lam cx pundc - B GP C frthis mason `l 1,'s,
owne, Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under 'Thy of perjury one of the following declu,tions:
❑ 1 have and will maintain u Certificate of Consent to velf-insure for Worker's
Compensaticm-a, provided for by Section 37M of the Labor Calc, for the
-. - 'permara meof the work far which this permit is issued.
❑1 have and will maintain Worker's'Compcnsaiion Insurance,as acquired by Section
17M of the Lahr Code,for the performance of the work for which this permit is
issued.M Worker,Countrwaina more came'lad Poll,Ydmber art: .x, ,., •, •.,.,. ,
1'.. Ya. Pe.,tion los ,. ... . .. .. ... .. ._. __ .. .. ... . . ,...._.
"CERTIFICATION OF,EKEM"ION FROM WORKERS" -
t'' COMPENSATION INSURANCE_', ° .
' u (This selron need not he completed it the Perm,is for one hundred d,llua
(SI W)or less.I
- Y a .: perms us issued.I .. ._ .. L , t
Iscem l that n the f c f the ark for which tbs
shall note_
employ any pawn in any manner so m to become subject to the Workers'
'C pe. ubn Laws I. fC fornix.Date f
..'Al]I ons LI .. . :. y . . . .. _.._.. .._
•'NOTICE TO APPLICANT:Wirk IL after making this Certificate,of Labor Call.you must `
'became subject to the Workers Compensation is pi.itshall the Wtor Calls.you man
Z Q
forthwith-w comply L' such provisions or this permit shall he deemed mvoketl.
�'.4 - CONSTRUCTION LENDING AGENCY,
�. 'Ih'entry strum that there construction l ding agency far the Performance ..I f
sof the work for wh,ch NC pcm,u s ipso d(Secy 309-1.Civ.C l
a:Q
o:z Cnde.r's Address.
C.7 , 1 cent ty,111.11 have tend this application and stem shut the above information is
F 2onen.1 agree m campy',with rill city and county ordinances and statelows relaing
a building IE 6 truer -d hereby cathodic P m rte f th i"t antupon
�.a La7 the above mentioneds pony f inspectionpuma
E.a 0. IWe 6 'm nJm fY nal ke pharmksa the Cty tClpetino against
Vl I ti 1'f m .R nJ pens h may inany ay ucc a ,gni ,said
-V.^ Ctyy' a nc gof tot ppm t
;APPLICA U S AUD W ILL C041PLY W'IT I.L NfON P bTQ O
souatE :cl Issued by: Dale
�wglaaofim otAptrielpfirAfmilartur Data 4 Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
WJl the applicant or.future building recupnnt more or Handle hetsidous oaten, Type of.Roof . . _ ,. .,....,_. _
al defined by the Cupertino Municipal,Cak Chapter 9.l_ and the Health and Safety
Code Sectio25532(01
❑
All roofs shall be.inspected prior to any roofing material being installed....-I
Will the app—aw - f MuTbc p�,t uxe eq P ..t d.ax which If a roof is installed without first obtaining an inspectton'tIt'agree to.remove
colla rd s,irconumtnnis as defied by the Bay Area A Q Iy Maingenmm
Dt,np, all new materials for inspection. Applicant understands.and.will comply-with
all non-point source regulaiions. "
I ha< read th h uNous mate Is requ rementx der Chapmrfb.95 of the
C hfom a th&Safety Coda Smions 26505 25513 aM SSU I untlersmrd,hat
t)g56bildi g oe tcunentivh tamnan,,than it is my msponsibiliry to notify the --- — -
desvpam o ,h q must h ctrl,prior missuance of a Cenifcam of
Occupancy. t
^• �� , „ •" t �� ��' Signature of Applicant _ Date
nn a ,,en,:• D,te All roof coverings to be Class "B"or better
_OFFICE.