00070065 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
OWNER'S NA 87 HUNTERSTON Pt APPLICATIO
PHONE: SANITARY N .
\•�Ju O O ARCUITECT/ENGINEER: BUILDING PERMIT INFO
m BLDG ELECT PLUMB MECH
aI_- I-1 1-1 IJ
z j LICENSED CONTRACTOR'S DECLARATION - fob Description
1 hereby affirm that I am licensed under provisions of Chapter (commencing
�_:nl with Section 70010)of Division 3 of the Business and Professions Code,and my license
¢y � is in full force and effect. -
3 Date as Lie.« VAULT(E) FLAT ROOF IN FAMILY ROOM, (N)
a C a Dale Lie.# r
��LLOg Iunderst:nd my plAn,Jhin beat en mdni"ae�m. SKYLIGHTS '
5 >
INTI p O License)Professional
e'er fins,I m dB11alpf f DECLARATION
CrumaON'-
ti S' 1 Hereby affirm Ihn 11. ,Breit faan the Cession is Lisamc Law cmurut thefinbut .
SSC].a which iacarson.(Section]ons• t.afte,improve,de Professions C,Je:AnY city lirenemy
C which inquires a permit to coe,,he alter,improve,diminish,or repair any alenore
e. that he sliveuance,rsuant to
oithe mvi%ion ofthe Contractors
hesee a Law(Chapter
Ihmheincing Npursoann7Shepf Division
3 of the Businrsl.lid Prinwon%Coro Sy. FL Floor Area .Valuation
(commencing he is c with Section]Wi)of Division 3 of the Business and ion.Any si (mil
or thatheis exempt therefrom anJ the haos fns the allege)exemption.Any violation
of Section](1 hall vanyapplicantfarnpermit wbjcrz the applicant acivil Penalty
of not more man eve hundred dello"l5500n, APN Number Occup•mcy Type
El 1,mowner of Sheproperty,lir hi x....Ieinwlm wages stheir sole le ser.atioq
5170001
will le the work,and the oil,I it ie not Inc',Lie offered for scot(Sec.91iq,
Bn.b,eaa nml art,Whons aaln:'rhe comm c,co,and e d Jeea ran work
Il to it Required Inspections
of t fix ow.Not btmds m.mprevea mneeh,mpr who encs rnen winkared or 3622101 1. 00
otfthnmgh his own however,t pmvidcd mut such improvements am not intended or
completion.
for.talc w however,me building lir improvement is sold within nae year or
mprove n,,the owner-builder will have She M1UNen of proving Shat he did not buildor
improve Ter px,pnse ur.wle.c 101 — FDUNDRTION '
fd
ofhepropenymoexcwdvelycontractingwithlicensedrmtmros 102 — PIERS l/berprajec,(Sat ](W,Business and I'tofessimw Code:)The Ctnmchn!a /• -Liv,does am apply m an mvntcr of properry who builds er impm,c,Siemens103 — UFER /(/o marten,for such projects will a contractors)licensed pursuant to the O
cont xtoda License w. 104 — REBRR
❑lam eaetnpt andm sec. ,B&P C for this rens"n105 — ANCHOR BOLTS
ne>Q Dme 7 Z ape
w 'r.NsrcnoNDecLARnnorv— 106 - -SEWER R . WATER
Increbyarrrtounder penanyerperiaryone ofthe following decwrnlenxI 202 — UNDERFLOOR PLUMBING
❑ 1 nave rad will maintain a Certircatc m Coawal m self-imine far wenkcrs 203 — UNDERFLOOR MECHANICAL
Co onensatimi. n provided for by Section 37W of the Lator Cole, for the
perfornsime if he wml,far which this perni,is issued. 204 — UNDERFLOOR FRAME
0 have and will maintain Worker's Compensation Insurance,to squired by Section 205 _ UNDERFLOOR INSULATION
37of me Labor Code,for me performance of the work far which this pertnit is 301 ROUGH PLUMBING
ssocd.My Worker's Compensntion Inwmece carrier and Policy number Bre:
Cartier roli,st 30T2 — TUB & OR SHOWER.
CERTIFICATION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 3ta3 — ROUGH MECHANICAL
rntis aeution nice not Is,eno,Dted if l,npmi
nrt i, dollarsn one n,mared n„tl304- — ROUGH ELECTRICAL
($BM)mless.l 305 —' FRAME _
I ceNry that in the performance of lie work for which this pcmID is issued,I - 306 — - HOLDOWNS ,
shall net employ any person in any manner se it,to become object to,he Wenkets'
Coopenminn Laws of California.Date
Applicant 307 — INSULATION
NOTICE TO APPLICAN'f:If,after making this Certificate of Exemption,you should 308 — SHEETROCK
Z0 0 become subject the Workers Copermation provisions of the Labor Code,you most
ttmforthw;mcomplywithsuchprovisionsorthispemmshallbedeemedawaked. 309 — EXTERIOR LATH
^ l/� CONSTRUCTION LENDINGAGE,NtCY . 310 — INTERIOR LATH
I hereby affirmbut mere is it ctmsn,ntion lending agency for the perfermuncc
et We work for which this permit is Issued(St.3097,Co,C.) 311 — SCRATCH COAT
o q L.•adcrs Nunuc31 3 — ROOF NAIL
:) lender's AJAress
U C lcertify that Ihave readthis apphcneonuadwee,hmm,me,einformation is 501 — FINRL ELECTRICAL ENERGY -
�. celacct,I agree to comply with all city and reality ordinances and&tale law%relating 502 — FINAL PLUMBING ENERGY
t.7 to holding construction,and hereby authorize apresemztives ofthis city m enter uptm
y m mean(We)a renedpve,indvNity B,rifyandknpueennie 503 — ,FINAL MECHANICAL ENERGY
F., 0. es.judgme m.cost andeifyocs whieep ch
She City of Bute ainoet said V) liabilities,judgments.cars and ing of this
which moy in any way ixcme against mid 504 — FINAL BU i LD I NG ENERGY
V Z APPLIcnnse UND of thegrantingof lis permd. 1 `l?
APPLICANT UND STANDS AND WILL COMPLY Wn'I ALL NON-POINT SOS — FINAL ELECTRICALDate "C `l/ 11-40
SOURCE 'U S. _ d
Signa cuf Applica 'oh6ncun waT Re-roofs —
HAZARDOUS MNMR1ALSDISCLOSURE 507 — FINAL PLUMBING
Will the opid art enramro IF ding nectnnmt store
n,handle b,aalloat a,atedw Type of Roof
Cdeerme C,tpemm,Mumcgnd cede.charter9lz.and ran He:dw amt Saro'y 508 — FINAL- MECHANICAL
Code,SSectionn 255320x0]
0yea 11No All roofs shall 50frlspectdaWRl_to ErfjAPffing material being installed.
Will the applicant or furore building tecupant use equipment or des ices which If a roof is inst5Ic@wiih4uulfii511.obPInf+lhIhKM0ection, l agree to remove
emit Imo duns air contaminants as defined by the Buy Area Air Quafity Mium,e nern
District's all❑Ne all new materi ilfgr inspFi"gLAgp tom.C pLrde {RgkSnd will comply with
all non-point source regulations.
1 have read the hazardous materials requirements under Chapter 6.95 of She
Culifomia Health at Safety Code,Serious 25505,25533 and 2553;I understand men
it the holding does net cnrremsy have a lenam.that'it is my responsibility to rally the
uvpant of that requ nemerts which must be met prior to issuance of u Certllitvm of
rlccnpnttcy.
Signature of Applicant Dale
Ownernrauthorized nl owe • - All roof coverings to be Class tB”or better
)