01010071CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION:
BUILDING ADDRESS:
PERMIT NO.
10922 NOVEMBER DR
01010071
OWNER'S NAM[:
APPLICATION SUR DA'Z'E
MCCOMB DALE A AND VICKI
D
01/18/2001
'ONE;
SANITARY NO CON not. NO.
ARCH I I HC'1'7ENG IN171:R:
BUILDING PERMIT INFO
IILIXI 'ELECT PLUMB MUCH
LICENSED CONTRACTOR'S DECLARATION
Job DeSCrI OO
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
x ith Seclinn 7000) of Dwision 3 of the Ibmonca mW Proo,,iolu Ctdc, and my license
I:I. full force and
iaensc Glass.._ 3p Lia.a_S X35
SHAKES TO 30 YEAR FELT
DECLARA 'ION
S D11CLm
An,
0.11 be use
I unscrsunJ my plans shall m: used us public mcoNs
I.icenud Professional
OWNTiII-BUILDER DECLARATION
I hereby affirm that I am exetnm from the Contra aWs Liceme Law for the
I'ollmving matom. (Secsia 17031.5, Business and VOQ,,ion, Cud, Any city or cnunry
which rcyWms a permit m co.I alter, huprnvc, dcmnlish, or repair any stmnum
le ignetl Oat rnum,
pri .r to Ila hvuuncu, aha.eylli a tin appliumn! r ouch peon W n f u,
FlA
Sy. FL Floor Area
Valuation
that he is bcensed pursuant m the powcons of the Contractors Uceue Lrw(Chapter 9
an,enein..
(cm gwithScclion70Soof )I,'i 13 It heIt...ineandpros„h ,ease)
I
$9950
r that he i, excmpt therefrom and the hoo, for the alleged exeunnum. Any mauu n
ohf Section 7031.5 by any applic:ml ba a Pcroun aunR'cn the at icum lots civil Firmly
of nm inme than lire hondrsl dollars DF410).
APN Number
Occupancy Type
362 ]. 6030. 00
01. ns owwo of Bre pronsm, or my emphiyec, with wages a, their sole ctnnlva.urron.
will doh the work, and the etmetme I, Bol lure led nr .1baed Iar cele (Sec. IfM4.
Business and Pndcoions Code:'fhe Comm lo,', 1 -wens, law does Bar apply,, an
Required Inspections
rroI property who huBd, Or imp se, mer .n. and who doe such work himself
305 — FRAME '
his od... is, pnwidm Inas such itnp we cut, am ria intended n
ofhmugh
fered an,We �t, however, the building or impm,cment i, mild within one year of
307 — INSULATION
completion. the o,rub- uildar will have the burden of itout he did inn mold Or
mpmvc for pamtne of nal°'l
601 — ROOF TEAR OFF
OLas owner of the pmpcny, am exclusively contracting with licensed coatraoun to
602 — ROOF PLYWOOD NAIL
the projcn (Sec. 0(144, Nsincy, unit 1'mfe,.In I, Cale) The C'nnlrnaan',
Lminuet
icense Law does no, apply m an ox.is, of prupeny who mtild, mimprn.e, thereon.
603 — ROOF BATTENS
and who ,,a .ra.'.. for such projc,o. wllh a contmoon,) licenced pursman m the
oe't, Use
— ROOF IN—PROGRESS
riI auto, ptunder604
O non exempt Uses . P k P C for Thi, reason
Owner Uktc
WORKER'S COMPENFAIION DECLARATION
1 hereby atirm tinder penalty of perjury one of the following deadiummus:
I loseVust tins rill maintain a Cenilicam of Consent ceLabourc for Worker's
t
hb......esot he mus Wed for by SectionII, sI... of the tutor Calc, for the
perfonnance al the work for xhich this, pcnnit i, imus.).
/r
/
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�1 have and will maintain worker's Compensation Inwndu is retluired by Section
uI of me Iothor cote I he parg,munme Of the work for which this sort, I,
iaueJ. My�cW''or��kerrs COmpc�tiop Touraine curtIcrlanndd�I'nlicy number
ier. W� f0 Policyr:
CartNo:; ---�
CERTIIBCdT'ION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thi, Genian need nnl he cn.nplwd if the permit I, or Inc hundred dollars
(SHXI or liens.)
I cenify that in IM1e perfommrae of the work for which this permit is issued, I
shall not employ any penal. in airy Iuanncr sn au In heconm subject lu the Workers'
Compemalion Lrws of Cdifarma. Date
Applicant
NOTICE IO APPLICANT, If, of n+ making this Cenlliara °f lixcmptim, you should
bce e,uhjsCl to the Worker, C nmpen,ul ton pro n Of the Lam Code, you Baer
forthwith comply with such pm,i%ions or this permit shall be deemed revnkcd.
'
CONSTRU=ON LENDING AGENCY
I hereby alit n That mem Is a comtmcton lending agency far the Wif°mh;mee
of,he work for which thi, pernot i, i„uoil (Sec. 3097. Co. C)
Lender', Nuns
Lender', A,k reo,
1 cenify that I have read this application and,late that the aMrve ialbrnmtion is
correct. I agree to comply with all city anti county ....Im Ice, and.oum law, minting
to building am,tmction, and hereby authorize repmuenmtiv s of this city to enter upr,
are abnvo-nentloned propery for imllecton Putpnsn.
(We)agree 10 mea. hWanuiT'y and keep moue,, the City of Cuscro againpl
Iiahilllies, judgmmnu, costs and expenses which may in any stay accrue agaimt widCity
con.,itio e.1 ere granting of th1, p ,,111.
I'LICANT IINDIr ISANDWII, CONIPLYWITHALLNC yr
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SOURCI3 NEG)1 R S. Vo t
Tram—
IssDCdb Date
y'
Re -roofs .
rmm of ApplZolCor acln�
iignm
HAZARDOUS AIATERLM S DISCLOSURE
Will the upplicam Or mums mldflllle nnatTmnl slum Or handle h vaNOns material
Type of Roof
as defined by the Cultist Municipal Cale. Chapter 9.12. and the Hcahh and safety
Cade. SW lin I o_5532WC
01e`
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant (it future mildingoccuromuse eyuipmamorde.ice,xmich
If a roof is installed without first obtaining an inspection, I agree to remove
cult h.,dmu aironair inanl,mdefined by the bay Arca Air Quality Manugemeul
WHO?
all new materials for inspection. Applicant understands and will comply with
El Y,, A -F_ 1
all non -point source regulations.
1 have w,d the Rai ... I (tutorials nonimmcros under Chapter 6.95 of the
California H.10i At Safety Code. Scclian, 25505. 25531 and 25534. 1 underamid that
tithe hotline toes hme;I that d 1, the
e /
nm OuTcmly count, Iny regmn,ihilaym notify
ocenic n, of t ret npnl, which ,I tie nil prim ut I.,tiance Of a Cem ;are of
O 'pa°
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O
Signature of Applict t Date
"B"
Owner or aanhorieed sem f)am
All roof coverings to be Class or better
OFFICE