01060075 CITYOFC DON
PFIRTNO
IPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
10223 S PORTAL AV A B S HEATING IS, AIR COND 01060075
OWNER'S NAME: APPLICATION SUB DATE
PICKLE ROBERT M AND LEONA A 334 SHAMROCK DR 06/12/2001
/ PHONE: SANITARY NO. CONTROL NO,
`1- (408) 238-7178
t9s O O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
'06
y<i LJ CUJ I-1 G.I
Z 5 N= LICENSED CONTRACTOR'S DECLARATION Job Description
O Z-O I hereby affirm that I am licensed under provisions of Chapmr 9(commencing
F a,-ad with Section 700G)af Dlvisian 3 ofthe Business ed profession,Code,and my license
=zea Lice full 11 rc<and effect/_�p Lie.« ���570 A/C UNIT
O d 0 DatenseSe s- A'OI Contractor
tato 3 u. / ARCHITECT'S DECLARATION
E u O J I understand my plum shall be used as public retards
cn¢E
w so o O Licensed Professional
a'at o ad', OWNER-BUILDER h rd the RATION
I hereby off nm that 1 am exempt from the Contractors Any c Law Int the
t_Z a vialla following reason.(Section 70313,Business and ,c,don els Code:Any city or county
ca o which requires v permit to construe,uhcq improve,demolish,err repair nny structure
ase pritarm as Ineards.Awhandine,he applicant I hoc It fI g 0 mmrom.
hn hasb0ca d pef,untt n 'Palki I he c t Li,can,Ido,(Lhpmr9 S 1't Flour Area-
(co aiming 'm Section 71)(0)of Divi. n3attheBus dP r sionsCove) ! i ')i^ x:C:e•�-t-0. , .` 'vt -�rL X11 aS.'• '
or he is exempt therefrom and the basis for the alliietl exempti na.Any violation
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
!of not marc than five launched dollars(5500). Occupancy Type
°1,as owner of the propos,or my employees with wages as their .to compensation.
will do The work:and the smuctum is not intended or offered for sale(Sec.7044.
•Busincks and Professions Code:The Commct°r's License Law does not apply to an 303 - ROUGH MEf $Q � 11(1%ppctions
owner of pmpeny Who builds or improves thereon,and who does such work himself
rthroughh" ply p such n improvements t intended _304 .-_. ROUGH, ELECTRICAL __
..-offichadf I If,however,"th building p m 1 . .-Id withinnoYcan of
completion.the bulde ll have the brdentp ng that hedid malar 505 - FINAL ELECTRICAL'
rep for purpose `. I ) 50.8 .. FINAL ,MECHANICAL
01 a fah gopeny I elyc rstct 8 with lice do m t rst. _. _ ._.......
construct the project(Sec 70,blBusiness and Pn f °ns CW )no Contractor's
License Law dideds not apply to an owner ofpm,my who builds of impasses thereon, i
.and who commentfor such projects with a condracharrhad limnced pursuant to Ne
Contractor's License Law
O I tors crept under Sec "B&P C for reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I lrcmby affirm under Penalty of perjury one of thefollowing declarations:
❑ 1 have and will maintain a Certificate of Consent to self-insure for Workers
_ Compensation. as provided for by Section 37W of the Lothian- Code. for the
Performance of the work for which this permit is issued.
°1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is
I use.M-/y�Woe�k,ers Compensation Irsmmnce candor and Policy number arc: [
Cuericr:.$11r1 "Policy No.: J✓a-Jc:O�]So JG c. .h,_a ..1 . .. f .. ., _ - _ -. .. .,_
CERTIFl OFEXEMPTON FROM WORKERS'I ', a a ` .-.• f..Q• J }-
-_.- COMPENSATION INSURANCE'"
s'(Thissenion rcoil not he completed if the permit is for one hundred dollars '-
($100)or less.)
I ttnify,thm. -_ -. _ .. ... .... .-. .-... -. - ... .- .. _. ..
in alis p in may
of the a,to became
this permit a issued.I
sIt.ll not employ try person in any manner so an to haame subject m the Workers' '
Compcmation Laws of Califomia.Date
Applicant
NOI'ICETOAPPLICANT:If:after making this Certificate
ld
of Exemption,you shou
become subject m the Weaker's Compensation provisions of the Lahr Code,you most
Z O forthwith comply with such provisions or this permit shall he deemed Invoked
'CONSTRUCTION LENDING AGENCY ' ' '
a > I hepab'affirm that there is a conaa°mion lending agency for the performance
�-Q of the work'for'which this— ... . - 1.permit is issued(Sec.307,Civ.C.1 __ _ _ __, . _-
Lenders Name- '. ... _._... ___ - - _ __ _ _.
�.Z Lender's Address'...
I certify that 1 have read this application and stat thatrhe above information is
fa F. correct.1 agree to comply with all city and county ordinances and slate laws palating
i. C,V to building conswction.and hemby,authorize representatives of this city to enter upon
>a"W the alnwe-mmrtianpit property for impecti°n pd,aoa,.
0.
(We)agree to e.indemnify and keep harmless
rovthe City of Cti,iinu against
.E. 0 Ii abilities.judgments,costs and expenses which may in any way accrue againa said
[) Z City in consequence of the granting of this Imrmit.
- APPLICANTUNDERSTAND. )WILL COMPLY WI fALLNON=POINT Issued by:
Date (O
5 RCE REGULATIONS., p L7 Y'
/ �l 'iJ�- lam- 7
signition:of Appfcanueantmclor Date Re-roofs
i HAZARDOUS MATERIALS DISCLOSURE
W.B'me applicant or future banding mcupant swam or handle na.atwas matddm Type of Roof .. .. . _... ._.. _.. .. .
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and safety .
Code.section 15532(a)? .l. !'i ' ` i ' 1 '.`'
°Yea '- °No " ' j _- All roofs.shall.be inspected prior.to any_roofing.material bei ng,installed.
W'illthe applicant orfumfe building occupant use equipment or devices which If a roof is installed without first obtaining an inspection; I agree.to remove
emit hazardous air conumirents as defined by the Bay Area Air Quality Management
nude: - all new materials for inspection. Applicant_understands.and will comply with
ores - r °No t - all non-point source regulations,, • . ,
I have mad the hazardous materials regaircmenn under Chapter 6,95 of the
California Health&Safety Code.Sections 25505.25533 and 255311 understand that
ifthesurno the not nmrtemly huve.a tensa, tjli is mg re..ince of
cianntify the
occupant of the
lie uircmems which must he met prior m iuuance of a Cenificam of
`apanoyy' Signature of Applicant Date
-
Ownerar utlanxddagent i Dare Al] roof coverings to be Class "B" or better
OFFICE
t