08090192 CITY OF CUPERTINO -
BUILDING DIVISION PERMIT CONTRACTOR T�IFORMAT IO,N
a,UF
PERMIT NO.
BUILgIrlciyply4 MIRA VISTA AVE TBD — TO BE DETERMINED 08090192
NEWS 7NAME: PERMIT ISSUE DAIS
BOB HENDRICKSON 09/30/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEEW BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED COND4ACTOWS DECLARATION
lr'U§ I hereby sffires mm I w licensed under prevision of Chapser 9(commencing Job Description
with Seetion 70dm MB of Division Sof Bud.and Professions Cattle.amy Ill..u SKYLIGHT OPENINGS 2-2X4
sin full force and effe a.
jai License Casa Lk.0
a„ Dam.Contractor
e
RIELTS DECLARATION
I understated MY plans shall W used W Public oemds
dU
t G G Licensed Prefessi...I
3 OWNER-BUILDER DECLARATION
.� 1 knotty affirm that 1 am uempr from Na Canuactor's Liccnm law for the
00 following reason.(Section 103 1.5,Business and Professions Cade:Any city or county
$ which requires a permit to canarva.altar,improve,demelHh,Or repair ay common
-zi prior m its issuance.also inquires the applicant for such permit to file a signed statement
< taut hu is licensed p..i to the provisions of the Contractor'.license law(Chpter 9 Sq.Ft. Floor Area p Valuation
ax (commencing with Section 1000)of Division 3 of the Business and Professions CM $
Crum) 20(]0
WI he is exempt thmefiom and the basis far the ulege l eamnptiom Any violation of
SocOm 1031.5 by any applicant for a Permit objocu the applicant to a civil penalty of Number Occas
not mom than five hundred dollars(SSW} 35705040 : Occupancy Type
0 I,as owrcr of the property,or my employees with wage as their son compensation,
will do the work,and the structure is Out intended or offered for sale(Sec.1014.Business
and Polnsdov Code:The Conuamor's Lixruu law does Out apply to as ownm of Required Inspections
property who builds ar ire prove dtercan.end who docs suc h work himself ar though his
own employees,provided lhatsueh improvements am not intended aroffeaed for all.If.
hw.ver,the building ar improvement is old within orc year of cmepletio t.the owrcs-
W ilder will have dre motion of proving that he did not Wild Or improve for purpose of
am.).
.u weer of the pmperty..Business
e mess a d convecting with:)Theed conva.nu U.censure the project(.1,.o as.Bnsiness,p rty win,ba Cade:)The Convector's rad
ocasswho contracts law doss not apply je ts owner of property IOW builds or improves theoan,and
LiceseLfor such projetts with a contractor(s)licensed pursuant to the Contractors
License Law.
❑lase sump.undosec.
44 ,Bd PCfor this resort '
rcr WOC1DF.l'P ! - - _ Dale
ER'1 .
ATION DECLARATION
I bunchy Nim under pcaalty of perjury,orc of the falmwing dichotoiwu:
0 I haw and will maintain a Cenifiate of Covent loslf-insum for Worknes Comocn.
saran,u provided for by Section 37110 of the Labor Code.for the pe,f...of the
work for which this permit is unit".
0 I haw and will maintain Workch Compensation Insvan¢,a required by Sdvrm
31110 of the labor Conn.for one performance of the work for which this permit in Wand.
My Worker's Compensation buurance canner snd Policy number arc:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thuseetian need not becompleted if the permit is Intone hundred dollars(31M)
or kis)
1 certify that in the Performance of the work for which this permit u Wood.1 shall not
employ anyp'nom in any manrcrso VTe Vbjee,mue Wormus-Compevaum
Taws of CAppliali( uc '�4y /3;r`
Laws tat
NOTICE TO APPLICANT.IL after muting this CcrtiEam of Eaemptan.you should
beeome subject to the Waheh Compensation previsions of the latter Code,you muss
., z faMwith comply wit such provisons or this peril shall he duomrA evaketf,
'Z..'O CONSTRUCDON LENDING AGENCY
t•+" I hereby Nirm dos then is a construction kndi.g.po:y for the perform.
a > the work for which this Permit Is issued(Soc.3091.Civ,C.)
Q under's Name
z fender'.Address
U O 1 comity that I have o n!this application and sate dist th„Ww information is
IL E cmrn<L I ague to comply with LI city ward county adinaaea and sate law,relating to
O Wilding construction,and hereby authorise rePresenutives ofthis city to enter one"the
r Lk7 ahbve-es judged propertyest for inspection puryorca
f+ D. (We)agree to ave,indemnify and keep hwamless the City of Capperfirm against
Z
liabilities judgmr thecosuand ea pensrarret. any in any wyacerce against said City
Uz APLICANce of UNDERSTANDS
of Nu per mit
'-" APPLICANT UNDERSTANDS ANO WILL COMPLY WITH ALL NON-POINT Issued by: Date
S/:UZ�P8�E ULATIGNS.
.rg�,tI orAPP � r�"'- 9/?nom Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding accupatsto a or handl.hamdous material
as dat by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
.Section 25532(.)1
OYe. ON. All roofs shall be inspected prior to any roofing material being installed.
Will dos applicant or future Wilding aceopam use equipment or ik,kox which If a roof is installed without first obtaining an inspection,I agree to remove
00-11
lcs erdnus uu
r conmimuds as defined by the Bay Area Air Quality Management all new materials for inspection.
OYv 0N
I haw mal the hasallou materials requimmmvueder Chapter Q95 ultra Cuifm-
-I-Hwlthk SafctyCok,.eetiov 25505,23533 and 25534.1 understand thatifthe Wilding
dma not eumnti ha •v^•^a that It is my responsibility or toffy the aceupat of ft
rtgaire roc be metpiarsoI...=OfaCutirNaefaevpwaoy. Signature ofApplieant Date
owrcr ar oat as,nt
Dam" All roof coverings to be Class';{"or better