04110115 CITY OF CUPERTINO
BUILDING DIVISION PERMITCONTRACT0RIN�'ORM, ION:. -
4A33
BUILDING ADDRESS: - - PERMITN004110115
19132 MURIET, LANE
OWNER'S NAME: PERMIT ISSUE DATE
COSTANTINO GISOTTI
E: SANITARY NO. CONTROL NO.
ARCHI'IECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION y J '1
C 1 homey )of that I un IicmuW underundPromu of Chapter 9(commencingsis Job Description 1.
L+ wish Section 7")of Division]of NC Business asW Profcssum Cock.and my license is ,vV• , w
in full force and effttl- 1 'i`. r/ -.
02 CJs CTua LJcs NEW POOL •, ( � � -
�1n_ Da¢ Contractorr
ARCHITECTSDECLARATION
EDECLL ARATION
I undersand my plans shallTS 4 used as public mrnrds
of Lweved Plofessiaal. - n/,p'�
j3 OWNER-BUILDER DECLARATION /�, r� -��
<2 1 hereby affnm Nn I am exempt from the Contractors License Law for the 'X/7/
p O following rtason.(Sauon](DCS,Business and Profesoon Code:Any city or county v`�/ '.
k zs� which mquims a permit no eomenum,alter,improv,demolish,m minor any structure 1J/ "�
Foypoor m is issuance.also requires dm applicant for such permil to file a signed sapmcnt
< oonn
Nathe)slieenscdNrmanttoNepmvisumsofshsConoxprfLicensclew(Chapter9 Sq.Ft. Floor Area Valuation -
e�s (commencing wish section 7")of Division J of the Business and Professions CnEe)or -
Nat he is eaempt Nmdrsom and Ne basis(m the allegW exemption.My violation of
Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom the Rm
K hundred doll.(s50)). e10 0 Occupancy Type
❑I,a&owForofdtepropmy,mmyemploymwiNwa wNeifmlec=Mnsmlon,
willdo New.rk.and Neswnum Isnot intended m ofemd forsale(Sec.]061,Business
and Professions Cade:The Comotem's License Law dna trot apply no an owner of. _Required Inspections
proper who buildsorimproves Nemon.and whoduessuch work himselfortitrough his .-
owne r.theeWiprovided pr sFohimprovementsarenot intendedmmRerM the ow.iL
however.the Welinbrien ofprovir,sat he didnot year of improve fon.r
Neame of -- -- -
builder will have Ne burden of proving Nat he did not builtl or improve for purpou of _
mk.
1,as ow al of On property,am Delusively contracting with,licensed anuamms to
cm(uoum the projce,(sec.91)44,Bulinus and Profession Cade:)The Conoacurrs U.
come Lew docs not apply to an owner of property who builds or improves Nemon,and
who convects for such projects with a contractor(s)limned pursuant no the Contractors
Lieenm Law.
❑lamaero r ec. ,B&PCfar suras
P .-
Owner Date _
WORKER'S COMPENSATION DECLARATION .
1 hereby aRmn uMcr penalty of perjury ore of the foliowto mons:
UnI have and will maintain a Cmdfinte of Covent toCook,fum for Warkcrs Comp the
ration, r provided for by section]900 of the Isbor Cade.for the per(armana of the
work for which this permit is issued.
❑1 have and will moment Workers Compensation Insurance,as required by section
3900 ofthe labm Code.for On performance of the work for which Out permit is issued. ----- `
My Workers Co n,ruadon Is tent carrier and Policy number me-
Carrier: Polity No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Des aecUrs,Food not he completsd if the permit is fmone hundred dollars($100)
nr less.)
1 ccnifv that in the perimero nce of Ne work for which this Nrmit is issued.I shall not
employ any,person in my murnerm as to keome subject to the Wmke Compenauun _
Laws of California.Dale
A,Ika n -
NOTICETO APPLICANT:IL after making this Certificate of Exemption,you should - --
become subject to the Worker's CoreNnation provision of Ne Lebm Code,you most
.Jz Forthwith comply with such pronsiata or this permit Nall be dcemM mnkcd.
Z p CONMUCDON LENDING AGENCY
Ihereby affirm that Nem is a construction lending agency for Nc performance of
0i> the work for which Nis permit is issued(Sec.3099.Civ.C.)
94
C) Lenders Namc
]z LcMer's Address
U Q I certify Nal I have read this application urd sue that the&hove information is
I3.P correct.I agree 0 comply with all city and county ordinances and sate laws relating to —'
0 building construction.and hereby auNoom monomfmiwes of Nis city m enter upon the [/'\,/7Iy(/�' ///J//�/y�� Q/
aMvetmcnuonWpmpcst for inspection
es whichpurposes. Y
H y (We)agree p save,indemnify and keep humless the City of Cupertino against
fn incoiectlus eofthecnts Fund expanses sthit. may in any way accrue against City
U z in conseganec of the
g ting of Nis permit.
^ APPLICANT UND TANDS AND WILL CO LY WITH ALL NON-P INT Issued by: Dat
SOURCE
N11,1111ton bf AMlicanaContractar )Fm, Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will IM applicant or future building occupant some orhandle WOun ous material
as defined by the CuNniT M Nepal Code.Chapter 9.11,and the Health and Safety
Code.Section 15531(e)dl All roofs shall be inspected prior to any roofing material being installed.
C]Y.
If a roof is installed without first obtainingan inspection,I agree to remove
Will pec appliu or forum bre ing Occupant use equipment or dcAcn which p
it hazardous air contaminants as defined by Ne Bay Area Air Quality Management all new materials for inspection.
Distom9
t]Ycs
I havcre adult
'mn]35U5.255J1 vu113536.1 undcrsoanA Nuif the Wi1Nng
dors rpt corm have a pnn4 Nu it u y reapomihility be nouly the acupan noun,
mvmm rt met rata _ rtifintemra� Signature of Applicant Date
Or Or anthariv=d as=rat Da All roof coverings to be Class "B"or better