00080163 CITY OF CUPIRTINOC WORKS
BUILDING DIVISION PERMIT CONTRACT NF I
BUILDING ADDRESS: PERMIT N0.
OWNER'S v is - APPLICATION SUB DATE
11477 LINDY PL ROWE CONSTRUCTION 00060IC13
PHONE; SANITARY NO. CONTROL No.
980 SMITH RE)
❑ 11jecti,ii
1HITF:C1'IIiNGINEER: BUILDING I`IiRM11T INpO
BLDG IiLECr I'hUMH MECH
W ca
ai, 33 ) 22-1.204 IJ I_I 1-1 L_I
¢ Job Descri tion
L rd that I a CONTRACTOR'S aIiCjn%ofC ON0 = I hcrchy affirm Iltm 1 am If h I under pnwi"'y of Chapter 9(nsmmcncingPFh all anel.1,14fYmisinn3 of the liuxincvsa I csumrs-Gra.at myliccmvcis is n full forte ILIA t. 15le 3QQa CnnlNtlOr_
V ARCITTECT'S DECLAR,f r 111 .I
tt=°g mlersl:Irmrmypl:mx.nrnnnnsrdasplrnli,rte""ia DEMOLITION OF EXISTING HOUSE
ad W Q o Lkened Professional
c z
OWNERBUILDERDECLARATION
H
v1 m I hereby utfirm that I am exempt from the Contractor's License Law for the
Q "llnwing Felt a n.l Scniun 71D 1 S,1lnsiness and Prol'assinns Catc:Any city or county
Z O which requires a permit to cunmruci alln,improve,drnumrd,or repair any structure
at
re priorto its issuance.alar acquires the applicant for.such permit o file a signed statement
mat he is fared puouant to the no kno,ofdre Contractors License La.(Chapter 9 Sq. Ft. Floor Area Valuation
ono mencing with Scnion 7000)of Division 3 of the Business and Pmfessinns Code)
,it than he is vwuupt IImicfnmt land he hrsis for the alleged exnnptinn.Any violation
it Section 71131.5 by any applicant An a permit object,the upplicam Io a civil penalty
,if nm mart than five hundred dollars[5810). A PN Number Occupancy Type
Cl Ln owner of the property.or my employees with wages as their sole compensation. '
will do the work,and Iltc,atomic Lv on, are led on,or'ni t liar late ser.70J4, 4 21
Bownto,and Pmitici ans Calc:The Common,,Lune Law rises tart amply In to Required Inspections
owner of property Who builds or improves thereon.and who thcx such work himself
through his own employees.provided that such improvements are not intended or 3564004. 00
niched for sale.If,however,the building or improvement is sold within one year of
mtplelin 1,thew
nncrhuilder will knu the human of proving than he did mal
or
novvelorpugwraetatude'` NO ASSIGNED INSPECTIONS
01,as owner of the property,am exclusively contracting with licensed contracton to
ntmmct the proiect Sec.7144,Business and pndesxluns Code:)The Conmamor's
License Law docs trot apply to an owner of property who melds or improves thereon,
and who enuresis for such prof whoa onnlraclons)licensed par%mml In the
Cnm.car,',License Use.
01 um exempt under See. ,13 B P C for this person
Owner Data
WORKI3N'5C(yMl'IiNtiAT10N DECLARATION
1 hereby aBirn under penalty of penury one of the following declaration:
❑ Ili J willse rain a Ccoill IConsent t sch-unscric for Wnkcrs N,
Coopcovidar, as provided far by Sit ]7N) of the Ution Code, lot the ,
f ce f the oak f which Thisman d.
I li 1 II 'nn Worker',C top 1 1 . i s mutinied by Section
171X1 or he Labor Crslr,tot the pmfomnnct,of Ihn work Int which liu psnn t is
issued./S`fy WoAd 's(C/n2nyc�nsmion n umnce cerziA/Ld(ppolicy
/n'�rjm/(rn�er�Oare
: ((��
Cu '(f<rLP RTII'ICA'fl( )'EXENIPT1ONe1tROt1 ORKIRS' \•
COMPENSATION INSURANCE
(This section need not W completed if the permit is for one hundred dollars
IS Ito)or vi
I certify that In the Ixrrornrmce or tire wurk'lirr which this permit is issued,I
shall Mat employ any ,.at in any manner so os In Wecom ti ,,Inc Workers
Coftenoon's Uws of Calimatia.Dam
Applicant
Nil CE10 APITICAN'P If.utar,narking Ihls Cri ifcam of Eschini..n,you should
become srhi lar theWorsets Co.overall...pm....trial the fall coll,you mail
O Q frtthv,ith comply with such provision,,,,this permit sholl be deemed revoked.
H % CONS'T'RUCTION LENDING AGENCY
1 hcrchy oBmn That mere s a eunstmetion lending agrney fa the Ixrfommna
r� of the work lin which his Iwnnit'is issued(sea.3197,Civ.C.)
0. Q Lsnder's Name
Z) z Lender's Address
U O 1"ally that I rave rend Ibis upprmmion and cote thus de arrive iallmnation Is
k. E.. correct.I ogres to comply with all city and county nrdinmtecs and state laws rclaing r
O O :.Wilding cunamctinn,and hereby aour.dre ot'hwereadver of this city it)enter upon
the aMwe.ttmmmond pm r urpoanal proposes. _ - -
ti0. 1Weingmem s: o.mi lify and keep narmlns the City of Criterion against 1
In hahuines,indgnmms, in,m cavils who It rorty' y a,cauo against said fr�.A�y /
U z City in conugrence the • ming rt(ani.perrtdl. a �(y/
APPLICANT UND RS DSAN WILLCO LY IT AL Issued by: Dale `
SOURCE REGU S.
Sigmmr,of m01nr V Data Re-roofs '.
1 VAROOUS MATERIALS DISCLOSURE
Will fix appf atmfuture Wilding overhaul armor mndlcfurmaskst,normal Type of Roof
as defined by'the Cupertino Mlunicipal Code,Chapter 9.12,and the Health and Safety
Cade,Stenon 25532(u)'!
0 Y., 0 N All roofs Shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use compound or devices which If a roof is installed without first obtaining an inspection. I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
Dixlrin9 all new materials for inspection. Applicant understands and will comply with
0Ye, 0Nn all non-point source regulations.
1 have rtad he and Icteric,requlremen,under Chapter 6,95 of the
ifinnia Ilealth&S. G c 5 Minns 255115.2551]and 11 -11,I understand mm
c building damn rrcnt him nlununl,Ili: it is my rtxmsmsihililymnoGfy the
capanl of the req r MCMI It mum hen Hit I i ,nf n Cort'" 'I
Occupori Signature of Applicant Date
ownarm Int .gen Dula All roof coverings to be Class "13-or better
OFFICE