01070058 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
22085 REGNART RD. VIA BUILDERS 01070058
OWNER'S NAME APPLICATION SUB DATE
CHRIS & CINDY HENRY 4600 EL CAMINO REAL 07/13/2001
�IPHONE: (650) 948-1077 SANITARY NO. CONTROL NO
C-Z ARCHITECTIENGINEER: BUILDING PERMIT INFO
002
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8 LICENSED CONTRACTOR'S DECLARATION Job Description
Z I hereby affirm that I am licensed matter provisions of Chapter 9(commencing
ln wiffi Section 70000of Diviona 3 m the B me,,and Pmfirs,xam;Code,and my license TEMP. POWER.
san fall force I e��tc(2. Lid.# 71-7 t3 0
mse itit
a:.-
Date Contractor %I I Far,5 A I _IUL,
a. RC.,TE,.S DECLARATION
I understand ory plans shall be used as public accands
Q
Ic
a, no Licensed Professional
a.
OWNER-BUILDER DECLARATION
�1 so I hereby affiron that I ism exempt from the Contractor I License Law for the
following peavan.(Section 7031.5.Business and PriL Code:Any city or county
C which requires a conat to cursome% Im,moprose.demolish.or repair say arroure $300
ou
u. ...is.1 1he Cmatrarm,I License Lunt,(Cl......9
(&Loam ing ,ith Section,70di))of Division 3 of the Business and Prolessirm,Code) its .3 3��IJ,8Tr,&Ua p-,, Valuation
ease
or that he i 4 cmimpt thFrcfrod and(he hasis for the ailegial�xempnimh.Any v iolation I
of Section 703 1�5 by any far.Perand,mbmas he p,l corou,.civil penalty
of not mom than five hundred dollars(SSW), 103 APN 6ft1kpir Occupancy Type
CI 1,as owner of the property.or my employees with wages as their onto compensation, RGUOK RIECTRI IAI
will do the work.and the structure is not intended or offered for sale(Sec.70cI4.
Businces,ard Parms6am,Code,The Compencim',License Law does not apply to an Required Inspections
owner of Fri who builds or improves themor,and who does such work himself
or through his own employees.provided that such improvements arc not intended or ------
offered fiv sale.If.mosever. he brildi.,ormapoverment is sold within one year of
completion.the awaser-buildcr idl have the burden orproving that he did not wild or
improve for purpose of sale.),
ith limrL-�contact.
[11,asowntrofthe property annexclaosetycentradfing w r,In
Z omme, he amee,Sce.7M4.lla,mc,,and P...fio,iam,C,Ac:)The Commerce's
License Laaw does ma,apply 1.an wre,ifffoopeat,who buld,-1 impome,loca-mr.
end who contracts.for.such.prui with,a commuzzat"s).ficeneacz!pursuant to the
Commerce's License Low.
ta _Z D I am exempt under Scc7 B&PCfar,his.
Choner Date
WORKER*S COMPENSATION DECLARATION
I hereby affiran%L re,malty of perjury,onic mIda,followim,dcclarrumms�
z 0 1 lb�ve end�;ill maindain a&raficam of Consent to self-insom for Worker't
7 Compensation. as providin] for by Section 37M of the Lator-Crit for the
efferarance of the work for which this permit is issued.
0 1 ha�c rumf Is ill mai parip Worker's C..,pnemsticto hoon,met,a,pc,rim�by Section
3700,of die'Laboir Code.for diz, gerficamourcie of the work for which this com,is
i...cal My Workers Compensation Insurance turner and!Policy number am:
5 7 utsi d6uit,,s�7,2
Carrier 5fr_1P1sT& ii"I"y Nor:
1,1�f ECERTIFICATION OF EXEMPTION FROM WORKERS�
COMPENSATION INSURANCE ...........
I 1 .1 . .. .: :� —, .I .J:
'C"Ibl,'sestini.a.d�.i be coacifleted if the Permit is for me hundred dollars
(SlI10)or less.)
A:. '�eaify into io' he p�rfmn`czrape of he Wfur which this peranit is issued.I
,shall not crople,any person in any manner so as to become subject to the,Workers"
Com,ensaticaLaosafCaliforma Date
Applicant
NOFCBTO APPLICANT: you should
Z become subject to theWorker's Compensation provisions of the Lahor Code.you must
C) Forthwith comply with such pmvisions or this crinat shall be deemed revoked.
Z
�' ' L ' CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a ctamthpu�cim lending agency(or the performance
I Bov.%ork for uhich.this peopit is issued(Sec-.3097.Cis,C) ... ....
;D;Z under I Address J
L) I cartify t ML I have re act this applicant,n and state that the above infinamation is
we., correct.I n,me to comply with at]city and county ordinances and mate Laws relating,
0 to wilding construction.and hcpb�authorize representativesof this city to enter upon
>, W i the dirse-mentioned property for 111%acerlm I)mmcIeS-
gW (we)agree indearnify arid keep hrionles,the Ca,of 6e,vatim,against
liabilities.judgments.costs and expenses which may in any way accruc against said
U Z 0 �izm u,�, I It N;au�,,of do,geope'. . , , , I 9=
IF-4LI con u L, S_ L D WILL COMPLY WITH ALL NON-POINT Issued by: Ate --7-1:3221
-1 R A IONS
I RL 1.4'A"
Si7greaturc OrAWWRoCoadmi Date Re-roofs
11 1 )SURE
HAZARDOUS MATERIALS DISCL(
Will lhe.pd.cz�l mfuttim buildingocca,cal,care m1b,toll.InDLLadma,andmanal Type of Roof ---- ---
as dcrn,d by the Carnorm III me al Code Chapero 12,and the Health and Safety*
ad,
Code,Section 2553'
ClYe,` a
All roofs-shall be',inspected-prior-to. By roofiner material being.installed..,
Willmea,licart mildur,asecturntri ate eq.,roaram,des.re,which If aroofis instal�ed'without firstobtaining an inspcctio�"T agree to remove
emit hazardous air onalatimar fired by he Ba,Arco Air Crain,
District.' all new materials for inspection. Applicant understands and will comply with-
13 yes N. all non-point source regulations,,
'ILI
I have.,I the th,toolon,materials oe,pireaticall der Chapter 6. a
California Health&Safety Cade,Sections 25505.25533 ard 25534 1 ,ad, ,.oil�� La
r,11`7NbVdI ra�,.=ptl'It
6m6i u fghe whiN am1`1.Z met prior to issuance of a Cerrificam of
4 6 - `7—l3i�-O,( Signature of Applicant Date
1C 1 E,
-Z or arthorimid agent All roof coverings to be bass "B"or better
Doe
OFFICE