00070177 CITY OF CUPERTINO
BUILDING DIVISION ' PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
OWNER'S NAME: AI'I'LICAIION SUB DATE
1.9831 LA MAR DR RESIDENTIAL HEATING ND A/C IN00070177
PHONE: SANITARY No CONTROL No,
JENSEN, REBECCA 65 CRISTICH LN 07/27/2000
C m Z ARCHITECIYENGINEER: BUILDING PIHtn11l'INPO
L°— 4083774073 Bim ELECTurvlB mraf
IJ 1=1 1-I G"1
z So" LICENSED CONTRACTORS DECLARATION
,� Job Description
V hoeby n1Erm that I as 3llcene ll under pmvisinn,of Chapter 9lcomnmcense
ONaC with Sccalnn 9rX)tpafUlvi,ion3ormc ltudnae,unJ Prol'u.vionx Cnde,unJ my license
S—f iv in lull fnrcr l effflll((('''yyg��k ��,
y¢< Liccnx flash r_C�3 —
" nucni'n;,:rs rnscl.nennoN
Iandchs.mlatyplans>fill bemardit,pnnrcrcenm, A/C ADDITIiMRINALED
s
u+=d o Licensed Professional
a. o�y OWNI;m exempt
treat
aEtheCom IDN 0 7 2001
= I mau (Sect thin 1. exempt front the Conlmcnhr'r License Law for the JUN
rz which rereawn.ermit it]03str5.B.sinm,andve,deaonz(]ode:Any eery Or county
O
which y permit construct,1 It P J h l'h repair any structure
gra 1 '1M1 'II. t ' 'hp rtll fl y d.nitel,ICnl
d3" morn 1 dgrsv nh n p 1 thet 1 t %s 1� 1Chaptcr9 Sq. FLFloor Area LDING valuation
(commencing s eeth SevenoWait)a nofhe basist(it the Run JIMf ,Code)
or that he i. 1.5 b therefrom nad the basic for the alleged exemption.Any I gamer
.if not
etha 5 v any hundred
doll
arra pennil eahj<d,the:yhpliemn In a CIV ll penalty
rrn.t hmne mnnr eh.nnrednrn.r,(35,Np. APN Number Occupancy Type ,
❑I.as owner of the progeny or my emplyces with wager as their sole compensation. $1
will do the work,and he xtmcmm is nnl intended Or ofleed fnr rule(Sec.]tA},
Business and Prolcxsio is Cole:The Contractor, accaw law deer art airily 1n an Required Inspections
Owner of progeny Who(wild.or improver thereon.and who doe,each work himself 3691.0030. 00 '
or through his own employee, provided that such improvcmems ore not intended or
littered for sale.It,however,the hnllding or impmvcnmm i,sold within ane year of
completion,the Owner buffer will have the burden of pnrvhag thin he did not hulld Or
improve fee"at,ofrale.). 204 — UNDERFLOOR FRAME
❑1,asvne,ofinepO,p,,i,,ait, ,c11..iely.rrmarinawithlicva,edcrmractor,in 301 — ROUGH PLUMBING
construct the project(Sec.70.44.Ravines,and Pour,,ion,Coda)'I he Cnntracmr's
License law does not apply to an owner of property who MWds or improves meeon. 303 — ROUGH MECHANICAL
and ra,l hr`,Li;...oc Law projects with rnh eo ,l licensed pa nam m me 304 — ROUGH ELECTRICAL
❑Ian,exempt ander Sea .13d1'C ter this ,.,an
505 — FINAL ELECTRICRL
Owner WORKER'S COMg17NSATION DECLARATION - 507 — F1 NAL PLUMBING
I hereby affirm under ferny of perjury title of follow ing declamhons: 508 — FINAL MECHANICAL
❑ 1 have Out ,If ,nain;,in .Ccnemam of Co..ent m,cf-iii,cre far Worker. 514 — FT NAL PUBLIC WORKS
Compensation, as provided for by Scannn 79118 of the Labor Code,.liar the
performance of the coal,fnr which this .it is issued.
❑1 have and will nntntain Worker's Couipersatinn moaruncc,as required by Section
371X1 of the Labor Coda for the lerfounow,of the work for which this hermit le
ivueJ.My Y111,16 Com minion Insurance carrier and policynumber
nnuum�berr(a'rc�:
palmy No�y�'j�.J� )�
CIiH'1'IAICAI'IONONI ENSA ION IN N RANO WOH t.
COMPENSATION INSURANCE '
(Phis Kation need not be<nnyfined If the gcnvu it fill one hundred dollars.
($100)ar fellJ
I emery than is the perrorm owe of the work for which this Not is issued.1
shall nut employ any,pare....in any nmince a,as to become.bjc,,to the Workers'
Com,nodua laws of Cadiforran Date
Applicant
NOl'ICE TO APPLICANT:If.after naking this Cenificale Of E,emption.you should
become xub]mt l..the Workers Cm..pc..,mian pn1111mux Orth.Labor Cecil,yen most
'
Q.0 for th comply with such p ne,don.,or tier permit shall be deenmd revoked. '
Z
[%] CONdiem is colo LANDING AGENCY
a > Ihae..ohinn that,hemins o,lod( et. lendingagency for me perfornrunco
,film work fnr whleh this Iwnnit i,Issued(Set.3119],Civ.C.)
:s: Q Lender's Name
�s Lcndern Address
V 1 torero mat I have read hm,argue-oast Ina,tree m.1 me abawe inrrhn,atnn i, - ,
correct.I ognee to Comply with all city and county ordinances and crate law,mining
U mhuilding con.amainn,uad hereby authunae representative,of this city to enter upon
the ahovo-llcut oned p opcny for inyhcction purposes.
F M. (We).grce to ave.indemnify and k p harmless l he City Of C.peninu ugahrs,
y liabilities,juJgmems,costs and e,pemes which may in say Cay accrue.,.in,,said
U z City in ronwqucnce of the griming of this pcmhit. �_���
APPLICAM'UNDENsSTA�'DSANUWILLCO YWTHALL ON-P ti\Bed by: Date
r4 SOURCE REG ILyyfylyJr
Signanam rf Appfican on a - - ate Re-roofs
IIAZ 011: N'F.HInLs DISCLOSURIi
Will the.r rr frit bu ding aee.pam store or handle h: Nom mill Type of Roof
as def rad by the Coem unicipal Celt Chapter 9.12,and the Health and Safety
Cola Sell
it 255321' . O No
El All roofs Shall be inspected prior to any roofing material being installed.
Will the applicant or future building ovcurymtuse egnipmemtirdevices coach If a roof is installed without first obtaining an inspection, I agree to remove
until haearaom air contaminants a,defined by the Bay Arca Air Quality Management
Divolef! all new materials for inspection. Applicant understands and will comply with
•�' 0Ycs 0 N all non-point source regulations.
I have read the humrdons materials requirements under Chapter 6.95 of the
Cali Gamin I let lth A,Saki,Code,Secllaa6 255115.25533 and 25571.1 mWemmrd that
if the building toe,not cuncmly have.mumu,111-1 It is any rc,pnalfl ility at nollly aha
necupam of the requirement,which must be mel print,to issuance of Certificate of
Occupancy' � Signature of Applicant Date
to aumadzed agent Date All roof coverings to be Class "B" or better
OFFICE