01070130 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10671 RANDY LA KOLLER JOSEPH M AND TERR D01070130
'OlU : JOSEPH M AND TERRI D Ari7Ln?r6�6131
p PHONE: SANITARY NO. CONTROL NO.
WOO ARCHITECT/ENGINEER: BUILDING PERMIT INFO
E BLDG ELECT PLUMB MECH
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0 S z LICENSED CONTRACTOR'S DECLARATION JobGE Description
oz,M Iherebya1Rrmthat 1nr3oftheBunder pddProleofo,Cade, (commencing REWIRE THE GARAGE .
p v_t F w wish Section s Lord e f Division J of me Business and Professions Cade,and my license
m y, is in full foae and cRcct.
¢z a Lice u Clus Lic.a
w 3 a h Doc S DECLAr
ARCHITECro DECLARATION
O g I unJcrsmnA my plans shall he uree as puhlic rtcoNs
a io Y Licensed Pmfcssional
OWNER-BUILDER DECLARATION
w1 hereby affirm that 1 cin exempt from the Contractor's License Law for the $600
.
F 5¢ Inllus Ing rv. i.IS.. n 1031 5,Basin=s unJ I'... ons Cid,Any city of color $6 O O
5d 0 which r=yuucs a "our,m ronarum,aloe,an,-,d—ohoh,or c,u,any ao,lum
x39 prior m its issuance akar requlas the applicant for such permit o rile a signed statement -
that heis.licensed pursuant td me provisions of the Contractors License Law(Chapter 9 i 31Cr.Old.04s ��a, ,k a Valuation
(commencing with Section 7")of Division J of the Business and Professions Cale) V ytS•,1. 6'111.-% '' '
or that he is exempt therefrom said the basis for the alleged exemption.Any violation '
of Section 7031.5 by any applicant for a permit subjects the cant team to a civil penalty M,ss..�.s.
[.four mom mar five hundred dollars S500). 304APN iflOVGH ELECTRIAL � Occupancy Type
❑l,as oanef orme pmpeny,of my emnlayas weh wagesas mei's.lecompensment, 501 — FINAL ELECTRI AL ENERGY
willBest.,,
.orae wore;animas oweThe is not mm',Linded en a eredLaw for my(Sec. to on 505 - FINAL ELI�'ggNAJ Ifils�ection5
Boar,of and ProfWhonb Code:The Co..dimes License law does not apply m an
owner of property Who builds or improves at such
sand who does such wink himself ,
or through his own limnloyen.provided that such ement is sol are not intendedyear of
or
for sale.IL however:the building or un en of ow n sold within one year of ,
completion,pu ownersaelder will have me When of proving that he did not mild or
tar ave for purpose of sale.).
csrm��Loxownerofinep(Sec.7,ant BusinissadProbvidwim Iianud.Cactnnm
muct me projen(Sec. to a owners and Pny who s Code:)The improves
tfasse, ,
Lic=nsh co does not apply m an owner of property who wilds orlpuns tM1to me
cul who contracts for such projects with a conuanor(s)lieensml pursuant to me
xLicense Law._ 01 amexempt under
S=c. / .B&P C,for this rtes �j
Owner • DotSATION,' 7 R J CI
WOR Eft'S COMPENDECLARATION f�j
I hereby affirm under penally of perjury one of the following declarations:
❑ I have and will maintain a Certiticote of Consent to ii-insure for Worker's /
Compensation, as provided for by Section 37W of the LaWr Cose. for the
performance of the work for which this permit is issued.
t]1 have mid will maintain Worker's Compensation Insurance,u requlrsd by Section
3100 of the Labor Cade,for the performance of the work for which this permit is
issued.My Worker's Coinpenamign M ematt carrier and Policy number arc: _
Cotten •. ' " '.` ( t-Policy No: tsl�tt_ (Jli •4;Y. 1 i - J t
CERTIFICATION OF EXEMP ION FROM WORRSRS'i < •s k t` ° f '
.,. -. COMI4NSATION INSURANCE ' " ....- - _.._...... . ___. _
(This section need not be title red if me fermi,is for one hundred di... -_
(SIDE)or less.)
•I certify than in the m in any manner
the wait force eh this permit a issued.1 t s .
Comnot employ any nelson in any manner so as to become subject to me Workers'
Compensnrion Wws of Celil"orniu.Dam '
NDnCETDAPo the Work If.Compensation
sats this previsions
sof of Labor Codyou should
st '
become su amply the Worker's Compensation provisions of the eeW'Code,you moa
00 forthwith comply with sato provisions or this permit shall be deemed evoked.
`^ f CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a conswmlon lending agency for the p afmmantt
of the work for which this permit is-sited i (Sec.3091.Civ.C.)
Q lender's Nm
ae
5' z Lender',Address
U � 1 certify that I have rend this npplicainn and sue that the.hove information is
L,s-.Fy correct.1 agree m ccmply wits alfeity and county ordinances and.state laws relating
O U tobuilding consuruction.andhereby authorize P rives oftM1 city to mer upon
the idsoconcrukated Property for nzpca pau,sme,
- i y 1 g e tonJ ton fy and which
hammy:the Cty f t pen a'agn nm
_ V] liabilities.judgments.costsJ amus hhi h y n any ) c g ma said _
U ,Z
Ch,m ufthe gr ring of this p t
APPLICANT UNDERS NDS ANF WJ COMPLY WITH ALL N N�P NT Issued by:
a[e ••�-�
SOUR PATI S: / 7 25/0/
Signam of App 'am/C°ntm tar . t ' ate Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the npalicaos or future building occupant'roto ar handle harridans nerenal Type of Roof
u defined by.the Cupertino Munici I Cola Chapter v.l?,and the Heahn ane gaiety -
Code.Section 25532Oo'. •s ) ' ' •' ,. •• . . r s
0YeS All roofs shall.be inspected prior_to.any.roofing material being.installed.
Will the.applicant of future building occupant use equipmmat or devices which If a roof is installed without first obtaining an inspection; I agree to remove
emit hnaardous tar contaminants as`defined by the Bay Arca Air Quality Management
District) all new materials for inspection. Applicant understands and will comply with
❑rex 7ki all non-point source regulations., .
I have read the hamrdws mumrials ac,immenu ands,Chapter 6.95 of the
Itfluantin Healm.F Safety Cafe-Sections255)5.25533 vad 25534.1 mmerstnnd the,lithe banding does not currently nave a tenant,that it is my responsibility to notify the .3.
coca aen
nt of the requiremts s t most be met prior to issuance of a C,ri cme of -
`y Signature of Applicant Date
7250/
Oe agent Date All roof coverings to be Class `13 or better
;.y .. . . . _ i... OFFICE