00080819 CITY OF CUPERTINO
BUILDING Dtvlsu°N PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PfRMI'1No
J
OWNER'S NA}Dg. ] APPLICNTION SUB DATE
�1tD44 LAURETTA DR f
S. "
IIONE, SANITARY NO. -_. CONT Rol.No.
LA
ARMSTRONG GRANT M AND BE F_RI_Y LHCI I I ECTANGIN EIIR: - (510) 303-1841BUILDING PERMIT INFO
WW ❑ BLDG ELLC'I' PLUMB NIECII
1_I [7-1L
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LICENSED CONfRd under SDECLARATION Job DCSCrIpt1D0
1 beeby al ata mu ofma U oiler mad profsion%sI C,+Cud 9 al mmenense 1
�_t-� with Sermon Y(NNO elf Divixion lof the BucincaanJ l'nsfn,ions Cudc.anA my license
' in full h+¢c nnJ el&ct,
c w U Lice Clac, Co b
i N Dale ARCHITECT'S
WATER HEATER
AR leall1Cuse a"uh RAf10N
1 unJeminnJ my plans,boll M1e asst ax Pnbllc be,nnly
E4oy_
ip hlccn,wA I'mfcainnal
that I.,i a.cnnDER m the ounce N
a v, I hereby ammo that l 1 exm+mt from this Cunvaa C s :Any c law for the
F z a which re rt:noa(Salton]NLS. t,aincsx and vet derami Calc:Any city acounty
ce r, witch requires o permit re amswn,alter,improve,demolish,or repair any xvement
prior m 1 l iamnce,also requires the visim uhf for such permit to ie s agar(statement
as= (commencing<ithSecLaonWallnfDaneof ion3o haBuen,rxueeneLnw(cnamers � Sq. FLFloor Area Valuation
(commencing C with t therefrom
om a of Division for
the Business and 11'olany'i Code)
or that he i,exempt.hacfmm add the basis furahe allege)esnnant to Any al tan ly
of Seat ane th shy anydredtippiwata ollrorupanni.xubicerc the npplicum muui,il penalty
olTol more than rive namarcd dollars($500). APN Number Occupane y
Cl h a,owner m the pmpeny,or my employee,with wages as Iheir,nle con+penxxtion.
will do the work,and the,porton its not intended or oBcrd rot sale Isee.'nua.
B 3EE54032R&�tired Inspections
i nes,and I'mc muorm m fe,rous C,dThe Contractor License Law ds pro an
wener of property Who bids or improves Henan,and who does such work hlmselr
or through his own employee,.provided that such impiovemen.s arc nal intended or 's
oBemd for sale.if,however,the building or impmvemem is sold within one year or — FINAL PLUMBING ENERGY
i,mplelion,pme owarolmilder win nave the bunlen nr pnrving Ila"he did old hand or 502
mrove tar purpose or sale). 506 — GAS TEST
❑I.asownerofthe properly.amaselasoclyemmaelingwith kcr,edrommemrslo 507 _ FINAL PLUMBING
msauea the pmjen(Scr.]dud.Business and Professions Cxdc.)The Cmnracmr's
License Law ducts not apply m an owner of property who builds or improves thereon.
and who r,License
for such projects with u comrnclarls'l licensed purnuum to the
El I It r,o Licenu law.
❑1 ion exempt under Sec. .B sr I'C for this rcu,un
Owner Date
WORKER'S COMPENSATION
on ofthe atio%iN
lhemhy affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Cowell u,sd6insurc far Worker's O
Comrynw.ion, as provided for by Section 37(X1 of the Labor Code. for the O
,en num,cot the work for which mix penin is issued.
Cl 1 have and will meimon Workcr'x Compen.xalien Inmmnm,as required by Seton
3908 of the Labor Code,Ibr the Perrarnunce of the wad,for whola this Permit is
,sued.My Workers Contpcn,aIa-Imummro carica and Policy number art:
Commit Ibllcy No.'.
CERTIFICATION Oh r:XEMPfION FROM WORKERS'
COMPENSATION INSURANCE
(Thi,section need nal be completed if the permit is for one hundred dollars
(5100)or le".)
1 cantly that in the performance of the wad for which this permit is issued,1
,hall nut employ any pular in any mamma a„as to he,ame,oh,ic, ,,the Workers _
Compensation Law,or Colilinniu.Dam
Aridan,
NO U.90 APPLICANT',IL alter making this Certlfuwc of Ezcmp.ion,you should
hemv
me subject to the WorkerI.Compc" ron provisions of the Lamar Code you must .• .
Q 0 forthwith ,,,reply with such providons or this pernit shall be darned revoked.
F g00 CONSI'RUCf1ON LENDING AGENCY
I hereby affirm that there No eI nswciion lending agency for the performance
onhe work for which mix rano.is issued(See 9097.Civ.C.)
L a Lender',Nmum
Z) Z Lender',Address
V 0 1 certify Nat 1 hme read this application and stats that the above information is
W E., coasted.I agme m comply win all city and comay oblimmcm and state lawsrelating
tj in hn'ddingcon,mall a.and hereby mahmizc m,m,cmmlvc,nf Nis city menla,upno
the aMwe-memioned property for inspection In rpmes.
Fa. (We)agmen,xnva,ruanamly and keep tamales,the Cayof Caperino ngainxl
to liabilities,judgment,,,costs and expenses which may in any way accrue against said
U Z City in comequenee of the sramins of Nu Perms.
^ APPLICAN']'UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT ISSU Date
SOURCE REGULATIONS. y'
SignummofnpphemWCanlmemr Date Re-roofs
IIAZARDOUS MATER1Al S DISCLOSURE
Will the alfliaea or furore building occupat,state nr her&hatcadomnutetial Type of Roof
mi I- d by me Cupculno Meniciaal Cade,Claaf cr 9.12,and the U,dm and Safely
C,dc,Sec.ion 2553'2 m?
D Yes ❑No All roofs shall be inspected prior to any roofing material being installed.
en,ItneWillme,:air:;muoi-fetm.oldrgaeuwnlatwequimnenfordevice, hich If a roof Is installed without first obtaining an inspection. 1 agree to remove
al by the Bay Arco Air Quality Management
Ddblel4 all new materials for inspection. Applicant understands and will comply with
0%a, ONo all non-point source regulations. .
I ha,c read the hazardous nuncrials minim ucas under Chapter 6,95 al the '
:alih mia llealth h Safety Code.Sections 25505,35513 and 25534.1 understand.hat
d.hc M1uilding dean nal mvmndy b:wc u enam,:hw it i,my rmpnn,ibiliry m nmify the _
IKcapam III the rcauircmenl,wheel+muxt be mel Prior I,I ix,uan"of a camli'me of
`y' Signature of Applicant Date
Owner oraamorlvedagent Date All roof coverings to be Class "13" or better
OFFICE.