06080075 CITY OF CUPERT[NO -°sf'� -
BUILDINCDIVISION PERMIT �CONTRAit '-SIN ATI,ON �-
BUILDINGADDRESS: x HUCK CONST. COMPANY Pa`aMRNo'06080075
10370 PALO VISTA RD
R'S NAME: PERMIT ISSUE DAM
PALLIPURAM 695 S . 15TH ST. 006
FIIONE: SANITARY NO. CONTROL NO.
(408) 298-2374
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG EIECf PLUMB MECH
O ( O O
00 LICENSED CONTRACTOR'S DECLARATION
u C 1 hereby affirm that 1 am licensed urvler pin"of Chapter 9 tcommencing Job Description
;]16 with Section7")ofDivisi..3 of lM Buriness and Professions dmy license is
,OH in full force andeffeel- '�y7Z �j SEISMIC UPGRADE FOR . EXISTING FOUNDATION & 12 NE
LiceDow, Lm'" PIER POSTS ON EXISTING FOOTINGS
Fp Dam Contractor
RCHITECsS DECLARATION
i s� 1 untlersund my plans shall W used as publi<recorm
Tau
o t, License)Professional
gOWNER-BUILDER DECLARATION
00 1 hereby a'.on 1.1 uempl fom the Contramoh License law for the
o O following maso (Section n.(S ]ID 1.5.Business and improve.
de i demolish.
Coda:Any city or county
j$� which requires a permit m construct,allu.improve,demolish,or repair any structure
prior to its issuance.also requires the applicant for such permitto rile a signed summent
�i
that he isw
licensed pursuant the provisi..of the Contractors License Low(Chapter 9 Sq.Ft. Floor Area
Valuat$Ii950
Elm (commencing with Seetion7000)of Divlskm3oflhe Busnevsand ProfcasioreCodc)or
$ that he is exempt therefrom end the huts for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit objects the applicant w a civil penalty of ��ps N Number Occupancy Type
not mom Yum live hundred dollars(M). 3 J /02051 . 0 0
❑1.as;wear of the preperty,Or my employee with wages re their sole compcnution,
will do the work,.edth.avuctum u.1intended molfertA forsake(Sac.7044.Busi. ns Required Inspections
and Professions Code:The Comrazmfs Limns.Law does mol apply laan Owner of q P
property who builds or immowes themon,and who doessuch work himselforthrough this
own employees,provided that such improvements are,Trot intended or oRand forsale U.
however,Ne building or improvement is sold within one year of completion,the owner.
build.,will have the burden of proving that he did nal Wild or improve for purpose of
sato I.
❑I.as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Peliumens Code:)The Contractors U.
tense Law does not apply or an owner of property who Wilds or impmvea thereon.and. ) `�
who contracts for such pmjcm with a contractor(s)licensed pumuanl w the Contractor ✓/
License Lon
❑Ism uemptunder See ,BdPC far Nis reason
Data b
WORKER'S COMPENSATION DECLARATION
t 1 hereby rill m uMm penalty of perjury one of the following declamations:
❑I have and will maintain a Certificate of Consent m self-insure for WokehCompen-
sation,as provided for by Section 37W of the labor Cada,for the performance of me
work for which this permit is issued.
❑1 have and will mainum Worker's Compensation Insurance,u required by Section
3700 of me LaEor Cods.for Ne Performanceafthe wok for which this permir tsiuma
MY-
y Warm O hpensaton Imumnp mrrlm and Polity number art:
Cartier. Polity No.: _
ER FlGTE �F EMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need out W completer if the permit is foram hundred dnBxu(SIM)
nr less)
I certify,Nat in Oc Performance of the work fm which this permit is issued.I shall not
amployan, mon, subject as bbec a subjeco Ye Worktri Campensation
Laws of Calif, ' a ( o
Applicant
NOTICE APPLICANT:If.after making this C.rdRcate of Exemption,you should
become o ject he the Workers Compensation previsions of the Labor Code,you most
.J z forthwith comply with such Provisions or mu permit shall W deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
[—� Ihereby affirm that then is a construction lending agency,(or do,performance of
Qi the work for which mu permit u issued(Sec.3097,Civ.C.)
W Q Lender Name
CL
.7 z Lender's Address
U Q 1 certify that 1 have mad this application and sure that the aWve information is
LL correct.I agree to comply with all city and county ordinances and sate laws relating to
O U Wilding conswetion,and hereby authodm mpresenutiver of this city to enter upon the
shove-mentioned pmpcny for inspection purposes.
H y (we)agree to sava.indemnify and keep harmless the City of Cupcnino again,
Uz ,noise.jnce of the
Standing expenses which may in any way accmc againstuid City ��lO
n consequence c the grunting of exthis permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE ULAMON
"__ S—Re-roofs
g u fhpplican on or Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ileapplicantmfuture buildingocupapt mored handle Health somateriel
Octet by the Cupertino Municipal Code.Chapter 9.13.and IW Health arhd Safety
Semior zsssza)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes �No
Will the applicant or forum building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haram oras air emmun imam u defined by the Bay Area Air Quality Management all new materials for inspection.
ITsuic17
❑Yes R No
In rtwl Ne hvaNrroxmaeratsrequiremcnnd under LTapterb.95 of me Cali(ory
nix H.Il aSafcty Code Scd.n505.25533and25534.1undcuundthmifthc building
Dees nal comm have a moan.lhar it u my responsibility to nodly the mcupanl of me
requite naw home m tpriorwissu as faeertfinteorOccuPxn y Signature of Applicant Date
Dw r othtmedag n9 Date- All roof coverings to be Class"B" or better