00060001 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: ��/�i}
BUILDING ADDRESS: PERMIT NO. =z4S111
1030 PE;NNINGTON 6A
s OWNER'S NAME: APPLICATION SUIt,J��k'j'b60001
I PHONE: WAN E! (3HEN SANITARY No. II�O YYIJ CONTROL NO,
06/01/2000
0- ARCHITECDENGWEER: BUILDING PERMIT INFO
0- BLDG ELECT PLUMB MECH
ai I� l-1 LII IJ
Job Description
LICENSED CONTRACTOR'S DECLARATION
ZO S g 1herebyIi,m7f affirm thin I Int oIThelicensed under pnd PrOl,of Chapter 9 0.aimmecense
I-=C J is in Scot lorec and edger.,ran 3 of the Businesssend Prnfc..innr Cndc,unA my license
5. in full flares and effect.
CS Lienuc Cls.,.,
F tr
d. Date Con
ARCIgiCC's DEC
LA
RATION
I mukratnd my
plan..hall be used is public nNoNs
de e a 5 Licensed Professional
OWNER-BUILDER DECLARATION DEMO OF EXISTING HOUSE
y R 1 hereby am.that 1 ran exempt from the Contractor's License Law for the
l5Z, following reason.(Section 9031.5,Busmen,and Professium Coco:Any city ar county
I E which requires a permit to comment,alter,improve,de;nolkh.or repair any%wewre
le prlorto Inc iwcuana'.ahs requirm;henpplicant for eneh i v Ian to file a signed statement
mat he is licensed parse d to the pmvtsi nine cnmructncs License Law(Cham Sq. F(. Floor Area Valuation
Iran ing with Sccion9000)of Divm30(lie Inas nd P;ufa, as GNe)
nu n
nr Sec io is 31.3 b early. la and the basin for the allege)exumpdnt.Any violation
of nal mars,
n by any applicant Ibr a prrniia svhJca,the applicant¢a u civil pvnvlty
liar tiro Imre man five natefea dollars astral. APN Number Occupancy
0t.d ownerofthe ad he drumyemployeeswith oroas theirrolecompensation.
will Business
the work,and the Calla:
rc is not intended ore Law for wear(Set.1.an
o Der on am srs,Who
old- has
Cnmmaemo%License Law arses rot apply m ankL squired Inspections
r ofh his se. em Huila.nr i aided that
such,and who arcs wrn wont:himself
or
offered for his own employees, building
tort mrn vem nt is%
ld all nm one year or
le for sale If,el,milhowevc the l have
(l era improvement vemmt Ix s ira h%e didhan one your of _
completion......fit the oose III lld¢will hour the burden tl proving thea he did not build or
ntpm v tura purpose of odes).
0I,ax nwnarof he pmlamy,ant exrwsively ema arnn, ,,It fcensed comrricum,In NO ASSIGNED INSPECTIONS
construct the projeo(Sec.111,14,Business and Prol..ma,Colli"a Contractor',
License law(lees not apply n)an owner of property who huilds or improves therron.
and who contracts for such pmjca,with a confmcor(s)licensed pursuant to the
Contractors License law.
01 am exempt under Sec. .B&1'C for this rumen
Owner Date
WORKER'S COMPHNSA'r10N DECLARATION
I hereby offrot under penalty of perjury one of It,following J,.elariamnv'.
-❑ I have and well rehane n a Certificate of Consent m ever iome for Warkar's
Compenwtian, as pro.iced Ibf by Sectio 390 of die I-ad, Codefor the -
perfnmmnce o[the work for which this pemria in issued.
01 have and will maintain Worker's Compensator,Insurance,as required by Section
3110 of the Lrbor Calc,far she performance of she work for which this peman is
issued.My Worker's Cotnpensmion Insurance canief and Policy number are:
Carrier: Policy No.:
CERI'IFICAI'ION 01s EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE
ffhls section need not he completed a the permit is liar Inc hundred dollar,
($1fxd nr less.)
I cilli fy nim in the perlimnancc of the work bar which this permit is issued,1
shall not employ any person in any manner so m In become subject to the Workers'
Compensation laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,ulie,making this CeniGcae of Exemption.you should
buo
become subject the Waders Compcnwm ou tirm p,.Maoof the Labor Cute,ymust
Q 0 forthwith comply with such provixinns or this permit shall he deemed revoked.
F .^Ni CONSI'RUC'I'ION].ENDING AGENCY
a ' Iha<hy ulfnnthtuthere le a constrvefiniJeading agency Iia the pcif
of the work to,which this,cantor A issued(Scar 31191,Civ.C.)
L Q Lender's Name
Q Z lactakr Address
f..I Q 1 verify that 1 have read this vpplicaaion and state that the above information i,
k. (.., correct.1 agree m comply with all city and emm"oNi......and state laws relining
Q V
to building construction.and hereby inamorite repm,emmi.es of this city to enter upon
ray) the aMwe-memianed i mpeny fill inspection puBxsrvs.
�.I l4, (Wr)agree to save.indemnity and keep harmless the City or Cupeni no against
Fr to liabilities,judgments,costs and experews which may in any way accrue against said ,
C„) Z City in comegvunce of she unitin,ot this permit.
^ A°I'p,IC 'f UNDERSTANDS ANU lIhL COMPLY WIIfI L 'ONP INT lssuedbY� Date
s .R IRE In.nT��N�
s(,7�t�= rlfFrK�cni�t�Rrr" v'^ / D Re-roofs
1{AZAHDOUS MAT,clualS r am a,SURii
WII thele,Cirantnr furoreipal Coe.Clarni,9.1nr, bundle hamNmn Safetyaterial Type of Roof
vsde.Se by the 32(a)?nn Municipal Code.Chrpier Y.¢,onA the Health and Safety
Code.Smion 255321u71
0Yes 0N All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit ha ardour air conmininunaa as dcfned by the Bay Area Air Quality Management
Diarwr! all new materials for inspection. Applicant understands and will comply with
0 Yes [2 No all non-point source regulations.
1 have rend the avardnu,materials requirements under Chapter 0.95 of the
California Hamill&Safety Code.Secants 25505,25533 and 25534.1 undemmnd thin
if the building does ma cunenny have a tenant.that it Is my resp:m,ihilay to notify the
rupvnt of the requirement,which must he met prior in issuance of a Certificate or
of^j'�'"p` Signature of Applicant Date
I wnv t erase
age. D,te All roof coverings to be Class"B"or better
OFFICE