01040033 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADURESS: PERMIT NO.
OWNER'S NAME: StR9 HYANNISPORT DR #4APPLICATION SUB 3i1
PHONE: SANITARY NO. DISE
C a1 Z ARCD THCUIiNGINHEW - r BUILDING PERMIT IN a)
F
BLI 1 PL M
Z6 ELE ECH
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LICENSED CONTRACTOR'S DECLARATION 106 DCSCrIpDOn
o m I hereby affirm Ihm into IlentwJ antler provisions of Chapter 9(conununcing
mS whh Senium]I1S ,fDvi 3u1 the Ba'n"mad Poue"ons Cade•amrt ease
in roll 9mra n
oaf Lleen Cln. t C Carl'. /0 75 REPIPE TO ABS INTERIOR BATHROOMYBEDRO
3 u Dme Commaor
3 RCH ECf'S DECLA A ION
�=0 g 1 unJcrsmnd ml�nscd as pub)c meoNs
d 6$ Licemed Predessinnal
�1�00
S o OWNER-BUILDER m Tim RNI Cordee N
t3 I hurchy u(Snn tnul fun eIm,hu from the Q,,in.,o e:Ar,c Law for Ne
7< following raven.permit
(Section]onstr Business and improve.
demolish.
Code:Any city accuracy
k$F❑ which rcquire.+v pennil to cone)Ilse,ober,improve,Jemoli l l or repo,any swNum '
'u}SC22 pat he iss i+euanca alwrryothe poappliam the CermnNs Lima Lawcamicall r9
that he ensing realwith
pursecaut tion 7000 pif Divisi of the he Hushesldcerse Wwons Code)
or
Sq. FL Floor Area Valuation '
(r that he
SatlonomanofUivSionJofealegedasand ion.AnyviCade)
,r Ihm ha is esetnpt therefrom and the basis for Inc ul,(ho exemption.Any l violation u .
of Seccor on than
5 v any applhundred
doll li,r u pemtil vubjenS the oppliaml In v civil peaky P 5
of am tome moa Bvu namdrednuuitt'a(sslkn. APN Number I Oecu w
01,as owner of the Pmpcn,or npemployees with wages aS theirsole cion,a ution,
will do the work,and the stmmum is not metal or offered for.sale(Sec.704T r
Business and Proesslohs QNe:The Contactor.License Law does not apply to an 3561.101.ReCPAd Inspections
r of property Who holds or itoproves thereon,and who doe.+such work himself
,,.nor
his own employees,provided that+acn itnpmvetnen¢ rc aamt intended or .
uttered I lc.It,nawever,fine bull+hrg ,,improv,nen,is wine within rote Fetor 304 — ROUGH ELECTRICAL
completion,the nwnar-huilJor will have the burden mf pmviny Ihm he did not hnild or -
impmvefit,porpnwolsaleJ. 501 — FINAL ELECTRICAL_ ENERGY
01,as owneroftheproperty.ams,cwsivelycontractingwithlicensedcuntacmato 505 — FINAL ELECTRICAL
onswct the project(Sas 7044,Business and Pmfosiom CWe:)The Combf
License Law does not apply to an owner of progeny who builds or improves Ihemon, -
and who contracts for.such projects with a contmetar(O licensed putstoun to the
Contractor's I3ccnw Luw. -
Olantcxengnundelff". ,R&PC rur lbxrea o - '
Omer ENS
WORKER'S COMPENSATION DECLARATION
I hereby affirm under peeapy of perjuryane of the following declaims , O
❑ 1 huue;rod will nmim, a Certificate of Conncnt to sell'-imam far Worker's -
Canion,a6un, as provided•fia by Section 3700 of the Labor Coic, for the s
perfnnancc of the work for which do,permit is
01 hasc and will maintain Worker's Compensation Insurance,as required by Nation
37W of the Labor Cede,for the perh,raance of the work for which this permit is -
issued.My Worker's Compensation Insurance currier and Policy number are:
! Crown Y-rA�L Policy shv O 0cl 7/ s- 0 ,
CIIRTI PICA'I]ON OF PXEMPefION FROM WORKS IIS'
COMPENSATION INSURANCE
(this wetion need not be completed if the permit is for one hundred dollars
It WE or less.)
1 eeni l'y thin in the perforneres,of the work for which this panni)is issued,1
Shull nal employ any persrn,in tory inumer so as to hce n is.subject to the Workers'
Cone,frouiun Law-sof Caffmnla,Ilam
Applicant
NOTICE To APPLICANT.IL after raking this Certificate of Exemption,you should
Z become subject me Worker's Compensation provisions oflhe Lubn C<de.you nest
0 0 foMwith p
comply with such mvisitri this permit
shell M deemed
Z rtvnked.
F Cnd INRUf a ran LENDING leading
AGENCY ,
a , - herchy aBprm Ihu)Ihcre i-ss evnam(Sec. 309th ng ugomcy[or the Pcdininorca. - +
W
of Lender's
work li,gwjtich this pennii is issued(Sec.3097,Civ.Cd
0. z Lender's Addm
� Z Lender's AJJrcss -
V 1 certify that 1 have mad this application and Stam that the all information is
GL Ey correct.1 a• •e to comply with all city and county ordinanac+and state laws relining
0 V R,buildlnp onamonal and heresy anflumi orpresmnmi,r-a this it,to ener upon
(<] be,, riene nal prop, y L, .merlon purpncev.
F ( gree to wso an and kmp narrtlax m City of Cupatin i agninx, '
IiubiL J men, cxpem ta
nsca which tory way Ott against said
C.7 City i, u t of a tin oflhis peit. P /n'
L ' iF f 'lS WILLC rmIWf 1N 'INT
NR Issued by: C/ei Dale .•� Y
f , ,
Si, real Apnc�umocumare t it .Iane
/ RC-roofs
HAZARDOUS MATERIAIS ISCLOSIi
Wlllicapoleaat,
at flattmbuild.e,,anap. fin—aher ficlewnmuu-naucom 'Type of Roof ..
as defined by the Cupcnina Municipal Csdc,C1iaPler o.l z.ane The Hcohh and Safety
Code,Section 25532(vl'I t
O Yes 0 N All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which I it roof is installed without first obtaining an inspection, I agree to remove
mit huearduba
ous air ,mnmms as dented by the Hay Area Air Quality Management
uimraIf all new materials for.inspection. .Applicant understands and will comply with
Ye :1 No
all non-point source regulations. '
1 e ead the haaNs is materials rcquitanene,under Chapter 695 of the
Cuthbert leaf &Safety C e,Scaipns 25505,S5And 25534.1 understand that
if the h ng mol carpe ly hu a lenanl,that it' ty resrymsdaft y m tify the
lac. a (t �< a or ,ixsumnc rest be met a Ce Beate of
rte pat — pl� Signature of Applicant Date
wads area a"a,— Date All roof coverings to be Class "B"or better
OFFICE