01010025 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10535 MIRA VISTA AV HENDRICKSON ROBERI M AND VIRG10104012.9
)WNI!R'S NAME: APPLICA'T'ION SUB DATE
HENDRICKSON ROBERT M R,11) VIRGI
I PHONE. SANITARY NO. CONI ROL NO,
II COO ARCHITECU iM1'GWCI!R: BUILDING PERMIT INTO
u_ BLDG Bl.liCf PLUMIt h1[CH
H C CI
SaN
H^ LICC i�n I a n E,vo d order p DECLARATION Job Description
z z m 1 hereby nllirm,hut um of [toed under pini of Charter,Code9 nit n c Ing
o —o �%�w
wlth Sect m70(mma...l"11'", nna..f the ltmmem unJP ;Ida;unn Cole.and my
¢,a,a sc liver-
is n full sure mW el'Icn.
gob IJ,c...Clase Lieu WATER HEATER
Dine Commetm
X 3 a y ARCIIIIECrS'DECLARATION
t=O g I understand my pl.ns rh.11 Named a public records
w ta O Lic met Profeuimmi
Oat I'un Iexempt from
the CoATbN
= I hereby affirm that L;u entre from the Cnntoam.(Cs License Law for the
1 Z a fountain.remua(Seninn car Lraca a nc%s and 1'ndeniunn Cole Any city nr county
0 tan M1ny r 'll I t Il r anamve, I nik p. any a u,rn
is. pool 1 n' n '.. 'V III^ I r 1 p ' e, file g Ch ham
idem 1 wdpue tint tw nn c 1 Y rel L (..pare) Sq. FL Floor Area Valuation
Rnmt he I,cwon ,loaxi, antied ehall, 3uIeBusmos.ulion.It A.,violation
or than he i.esempl thercrmm unJ n basis for the alleged,, hGumption.AnY vinlra fly
or Smith them iv anydred antforapermil.unjsel..Ihe applicant foacivil penally
anhm mare man Five mmnamd daEm.astral. APN Number Occupancy Type
01,as owner m the pmpi nay employees with wages:m Iheir side vxonavn.minn, 3570504171 CAM
will do the work,and the structure I%not intended or offered for sale(Sec.70H1.
Business and accessions Calc nae Contractor'.%License law dies not apply to on Required Inspections
tans of pmpeny Who builds or.nhpnwes theme,mad who ma,i, ueh .,it himself
or thmagh his own en,ployce..pmv;dee dint such improvements are ant intended ar 502 — FINAL PLUMBING ENERGY
olfeecd It,s.11.E:hnwevcr the hall m improvement i, oldwithin one yea of 506 — GAS TEST
ar n..ralion,the owner-milder will lore J,e t...len of prosin i mal he did Bel mild or
Impm.crmpurpn.Gnl.IJe). 507 — FINAL PLUMBING'
01,..%owner none PoTI .am escladvely contracting with Lccnsed connectors to
Lmomal the peapof(Sec.7(W.Burin,,and N fieshinn.Code:)The The(Comct 'x -
ccree law does stn apply In an owner of pmKny who build%or improves thernm.
and who come.¢ter sa 66 pmjens witb m
a corocu,gsl licensed J puto the
ContmctoLicca /
pl
am
v J ILL�(c_ .11%t PClonhis reawn
n WORK tR'S l)dPI1N5ATION !..ARAI'ION -
I herebyand slllmh under pommy nr pale of
al rant tullow.ng declarations
• C 1 have and a% provided
f Cenilicam of Consent m edLiwn for Worker's
Compenraceo a tock fed for by Senior 37W of the IaMr Code, I'or IhG I
perLnmance of the work for which this permit is issued, /
01 have and will nmintain Worker's Cnmpenmtion Lnsureme.as required by Section
31011 at the Labor Gale,rot one pedurrica a of the ,,,it for which this penal is
wed.My Worker's Cmnp:mation Insurance currier and Policy number are:
Carrier: Policy Ne:
CEKI VICA'1'ION 01'EXI!MPI'ION FROM WORK1216'
•COMPENSA'I ION INSURANCE! -
enk taction need not be completed if the rennin is for one hundred dollar,.
(SIM)or less.)
1 cenify that in the performance of the xork for which this permit is issued,1
shall not employ any person in any manner m as to become sullen to the Workers'
Co ubse-i..n Laws of Calilomm.Dae
A,llcam hnald
NOTICE TO APPL.ICAN'1;11.after making Ila Ccnifica c u1'Vwn'te.m,you s
hall le smbleet a me Wniker'a Cnnlpervation pmvi.inns of the Labor Code,you must
CO Ii...faith comply will,such pit)....... or this permit shall he d.mtavl.,.keds -
F
CONS T RUM ION LENDING AGENCY
I hereby affirm that Them I%it construction lending agency for the permum ance
k1 of the work for which this rennin is iamed(Sec.3097.Civ.C.)
S Q Under',Name
= Z Leader',Address
U O 1 lemev that I have read this application and state than theamore information is
W E.. 1o"ll.1 agree to cmnply with all city and county nedhmnees and state law%m1ming
U to omking co.s,na,liver and hereby uall...ill braclantalives of thincity hamster spun
�y Lit tie nnnvo-mentnacd pmpmly for i-pemion p mfosr•
F.t It i (We)agm,al nave,Indmnnil'Y told keep hu....less the Cilyor Commas ag4irq
h .iarrhars.ludgnsnn nit caVcnsas which may In any way waaa against said
U 'Z, L'itY in c..ea .nal th• rating of this pn»in. T e
PYLIC UNDe A SAND LLL COMPLY WITH ALL NON-POIM' Issued b3` !CT ��-7 Date
00' AT N.
Sigmmmof Appbe n/' rEm Data Re-roofs -
HAV Nrl MATERIALS DISCLOSURE
Win me a,fic.m ar rutum building.,GG9,.,.a,,are of handle hmw,a
us ma,cdal Type of Roof
a%derned by the CuterI MoniC'pu,Codcha'let 9.12.unit the Health and Safety
Code.Section 255321;.7
Oyes All roofs shall be inspected prior to any roofing material being installed.
Will the applicant ahme build......Import uta¢yorneen,or device,.which If a roof is installed without first obtaining an inspection, 1 agree to remove
cont humrdair r contaminunfsa% feline by the B uy Area Au Quality Management
Di.Hic17 all new materials for inspection. Applicant understands and will comply with
o Ye. all non-point source regulations.
1 have read fluehaemdous malerm,ra uirvnents undo Chapter 6.95 of the
Colifomia Health R Safely C lions 25505.'_5533 and 25534.1 underemndthm
It the holding does end a m.am.that's is my rep arsihihty to notify the
cupan,rf quiro which must d:mon prier ur issuance Bra Con cam ul
oecnp: Signature of Applicant Date
- mammri,G (y62= 6G All roof coverings to be Class `B" or better
OFFICE