00080056 CITY OF CUPERTINO - PERMIT No,
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:' p Q o g'Q
BUILDINGADDRUSS: L
• 10460 OAKVILLE RV BALL MRRION K PND—J'6aT+16+ rN tiWl' ATe
OWNER'S NAME: BALL MARION K AND JAMES R TRUS N/C
PHONC: ❑
ARC]III'ECT/ENGINEER [CLUING PERMIT INFO
M00
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LICENSEDCONTRACnder mviCLARATION Job Description
zOv-
1 hereby afrnrm that 1 sen Ilommod uMtt Dov fM Of Chores 9 My lm oeing p
�°_ ' w h5«ion 000)ofDi xio 3ard BuunnsvtlPofwiomCod.sdmyl ueis ELECT PANEL
a � in full force and eRcct.
Exna
d O 6 V IJanse Clan Lia N
I e LL Date Conrrvctw
H
F O� ARCHrfECI'S DECLARATON
1 understand my plans short strand as public reoads
w ic o O Licensed recessional
^_ OWNER.BUB.DER DECLARATION
1 hereby amem that 1 am exempt from the Contractors License Lou,fm[be
following macs.(Section 7031.5.Business and prefeuiau Cade:Any city or county
i3= which regdires a permit on co man,alter,improve,demolish,m tcpm any nommum Sq. Ft. Floor Area Valuation
prim m its i....em.she rtgmms the applicant for such commit to file a sigmd statement
that he is licensed purausnt m the provisions of the Convectors License law(Clupter 9 $1
(commend,with Section 700(I)of Division 3ofthe Box.and Professions Code)m APN Number Occupancy Type
But he is exempt therefrom and rhe basis for the alleged csemption.My violation,of
Section 7031.5 by any applicant for a permit mbjects the applicant to a civil paulry of
pt mom Ilan five hundred dollars(5500).
Required Inspections
willdo the week,and the emse tum,is tout intended modfned for We(Sec.7044.Business
sed pmfeWam Core:The Co....'.Li«nee law dace out apply m an comer a 304 — ROUGH ELECTRICAL
property who builds or improve,themnn,and who dome each work himself or thmagh
his awn employees,provided that such impmvemsts are not inRMm or offered for 501 — FINAL ELECTRICAL ENERGY
We.If.hcwcvm.the Wilding w impturommot is mid within One she 5@5 — FINAL ELECTRICAL
y�ywa�will have the tandem ofpmnot bunor that W did nd improve r« r
pa
W r,mowm
r of the pmpeny,am exclusively convecting with licensed contranon to
construct the project(Sec.7044,Business and Professions Code)The Contractor's Li-
cm.Law docs nil apply to anowner or property wed Wild.or impavea damom,and
wed contracts for such projects with a comments)licensed Purtmen m toe ContMors
E]lar law. �/
Li 1sirs hemp under Sec. .B&PCfor this rtumn
Ownerx� �" / p, Uf 82nd 0
WORKER'S COMPENSATION DECLARATION O/
1 hereby aRrrnr under penalty of perjury We of the folloving dalantiom:
lheve and wild!for bineCeni 37M of tansentmCodenmr the Wmkera Compere
cation,as provided for mi Section 3700 of the Labor Code.for the performance of the
work have
which this pemdi is issued.
❑1 have and will maintain wneker's CreopmWicanw rkbrommuce.which
h required by Sadao
My ofrhelabor Code for theperformancecuveofthework(orwhichthus Remitisissued
.
My Carrier
s Compenution Insurance caner and Policy number w:
Cartier Policy
r
CERTIFICATEOF N MGM WORKERS'
COMPENSATION INSURANCE
(This aatian sad ata be completed if do permit is rmronchuMml dellen(g100)
of less.)
I ecnify Wt in the perfmon aof Ne work for which this permit is issued,]shut]
ben employ my person in my manner sm as to become subjal to the Wmkere'Compn-
sation Laws of Caliharem.Dau
Applicant
NOTICE TO APPLICANT:If,afar making this Certificate of Exemption,you should
hecorm subjal to the Workers Compensation provisions or the LOWr Code,you mus
forthwith comply with such Provisions or this permit mall W deemed revoked.
CONSTRUCDON LENDING AGENCY
Q (hereby mono thou then is a constmctin lending agency for the performance of
Z the work for which this permit is umM(Sm.3097,Civ.C.)
ISMces Name
7 LendeesAddressE I certify WI 1 have nM this apprentice and sum that Ne above infomurim is
A4 z comet.I agsee to comply with all city and county ordinances and sun laws relating to
7 Z building construction.and hereby mdom.representatives of this city to enter upon Ne
V 0 aw"..mioned property fee inspection purposes. -
Li Eco (We)agree to save.indemnify and keep harmless the City of CaPcrtino almost
U limikorx.jndgmene,cmc and expemaes which may in eery way am.against said City
} Lel in eensequcme of the grating of this permit.
[- % APPLICANT UNDERSTANDS AND WI LI.COMPLY WI'I ALL NON-POINT
f..) z Sou CE REM ATIONS. fns^
a 2Q�Q
.igmmre of Applicsnt/Conuacmr Date
HATARDOUS MATERIALS DISCLOSURE
Will Ne.ppucautm fuurt Wilding ocnpmntmed,handle by doss matarial Re-roofs
as defined by the Capmino Municipal Code,Chapter 9.12,and the Health and Safcry Type of Roof
Codr.Smoon 25532(a)1 yP
❑Ys 0N
Will the applicant or future Wilding occupant use equipmcm or devices which All roofs shall be inspected prior to any roofing material being
it huudous aircontanimnta udcflned by lbe Bay Arca Av Qumiry Managcmnt installed. If a roof is Installed without first obtaining an inspection
ales,❑Y [I No I a ree to remove all new materials for inspection. Applicant
Ihee es medthe hsc edea.m>tadm.m9airemmtaunderChapter6.95oftheemi. un erstands and will comply with all non point source regulations.
forms HmIth B Safety Code,Sectimu 25505.25533 and 25534.I understand Rod if the
huilding does nm cuneudy MI.(num,tha it is my n]soled iliry to notify the omolum
f the requh name which must be met prim ro hsuy�of a Cenificale of occupancy.
,[ .�a 2 ;4: / Ari6 A. Zona Signature of Applicant Date
F ren-flonaed agent Dau
All roof coverings to be Class"B"or better
OFFICE