00080086CITY OF CUPERTINO
CONTRACTOR INFORMATION:
BUILDING DIVISION PERMIT
BUILDING ADDRESS
PERMIT No
OWNER'S NAbu2;21 j6i' RE
APPI.ICXTION SIU I )00"
PHONE: GUDMI-INDSON
17AII 1AR1 NO. 1O lW) 10 ,
Z ARCHITECUENGIN[ER:
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BUILDING PERMI'1'INPO
O
RI.DG ELECT PLUMB AIECH
•I.a�.l G�I I_I I_I
IJCBNSIiO CONT'RACTOR'S DI2CLARXI ION
lob Description
1 narahy ullirm thot 1 ma Iiacnad under "I'viv'ionr,( Chain¢, 91. ..... ancing
a. with Section 7") of On ion 3ofhe BU,ineWand Pmfes. ins, Core.l my licenw
an fall :frltf Jkvi�� Sop 9
U Date C u,s Sr•7 D Lic. « /
Date Commdor�
v
SWIMMING POOL AND SPA
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AHCHIl1iCr'S DECLARATION
d
1 untlammml ndY prom .null Iw Hind n, public records
JJJ
-❑' LicemeJ I'ndfes,ional
OWNER-BUILDER
..a an the HA'nON
senn, Limy Law fur ma
1 hereby ,(firm .11 1 um exunpl (nun the
essions Coo Any city or county.
>' on c
following temoa. Ionian 703 L5. Business and
n Ill, P' y ,mdurc
which ve. deions li or
❑ which (' ,In I I
li b III 1 'g J 1 d me n
a the I t
Pro d t u 4
Sy. Ft. Floor Area
D:1110
e mpa La (Chapter e)
- man licensed pursuant theprovisions Ih C ,
e,4.'
ofelovi 3of the Hui.. assand1'rofApohslm
@l
or the he vwl
Retc r Anyl croon
or Seal he is'31.5b,anyapnt,nJ the lo
'
of Section ]Bl LS mnt sthectsthd pphoonn,
applicant far, pandit subjects thc,pplicam m a civil pcwlly
APN Number
Occupy c
,any
,ruin mina than n,e Hundred anH,s (s5,xly
01, oe owner,( the Pmpeny, nr my employee, all lase —, their.ade arnn,re -ned.
3664501 ' I 1'ed Inspections
will do die work, all the structure is not intended or offered for ,ale (Sol. 70H9.
lbr ,ud Prole m Cauld The CanInaln , Lire Law docn na' apply la un
r`tu'propeny Whot build, or ilnpmse, dtercon. ,ad who doe, such work himself
'
nthrough his own employees. provided that such improvement%am not intended to
lot B, bowevar, the building ar imprnvumcar Ix sold within .... a of
— UFER
olNir,d talc. yerr,
e d,dajnn, the nwmer-builder will have he burden of pnaing thm he did no, hand or
103 -
imp cc cc for Parposenf sale.p
1.04 — REBAR -
❑ I. a., Is, no, ,I de pmpary. at escmsively eotnraeling w'if, (,cored coronetor, In
107 — POOL/ BONDING
construct the project (ree. ]fWJ, Im,inn % and Profession% CWc:) ]be Contractor's
holdS 'hereon.
301. — ROUGH PLUMBING
License I,rw does not apply lo an owner or Property vilm or FaVowes
and who sonaace lie wa'h projects with a conn,a,artxl Iicclowd pnnu;iut to the
304 — ROUGH ELECTRICAL
ContracmrsLicenselaw.
❑Iamaseotpl,nwcrSec. .Bxrero, this mason
50 2 — FINAL PLUMBING ENERGY
Own" WORKER'sCOMPENSATIONDECISRAT1aN
503 — FINAL MECHANICAL ENERGY
I hereby affirm under Penalty of perjury one afthe fdlou;ng declarations :
506 — GAS TEST
11❑ I have lad will ntaintnin ;, Certificate of crawn, a, ,elf -imnta rot worker',
510 — FINAL PLANNING
C 1. x, prvided for by Scott o.1 3700 of the Labor Code. 1b, '11,
511 — FINAL POOL
perro,m,ncc of the work for which this pandit is issued.
516 —' FINAL BUILDING
CIhave and will maintain WndeL,Cmnpcnv,in I loomecc, a, np,mmd by See,
3](x1 of the Udwr Cale. for the petfnnum ct, of the work for which this permit is
i,sucd. My Worker's Cu/rnr ca11,Jnon Insurance carrier and Policy nut door are
-
tvt,0 Policy No: WN 44 -7 b 7ag8'61
C,mienK�ntirb
cKin iPICAfION Oli EXEMPTION FROM WORKERS'
COMPENSAil ION INSURANCE
his section need not M compldcd if the permit is for one hundred Ill
[4111(ry or Icx,.l
1 certify that in the pcefonno . of the work for xhich this permit is issued, 1
shall and ....ploy any li000n at ;ray nuamcr %o as ,, her nn.I, whod to ,he Worker:
Compen,dwo Lam, of Culitbmia. Da¢
Applicmn
NOIICE'10 APPI.ICANI: It, al'mr making his Certificate of Exnnpdioa you should
Z hcnme object tie Worker r, C'nntPerot It provision, Ill the Labor Code. You must
., forthwith comply with such pmvisiuns or this permit %hall M deemed revoked.
CON STRUC'I'ION Udeld NO AG LNCY
7 1 hereby alimuh,t mete is a cumlmdion lending agency for the performance
of the wuA for which his panda, i., issued (Sec. DIN/], Civ. C.)
[.elder's Name
7 Lemi,,'%Adl
1 «nify Na, I hove rc,d do, elplldnlon and late tlutt the ,buvn infonnainu is
mincer. I .,me Io comply with .11 city and county ordinance %and ome ]aw'n relating
;) bd buildingconslrudiun, and hereby authorize reproornatives ofmi%ciry mender umm
-
W the uhoveancmlmmd pmlxrly rot o "clone parpnm,.
y (Wei agme ad eve. indcandly and keep harmless he City or Cupanlno ag,in%I
A Iiubilides, judgment,, costs and expense, . which may is any way ,me against %aid
Z :try maoamqumao of he gmnfng of this Plorr"
APPLICANTUNDERST KIDS AND W I.4. COMPLY WITH ALL NON -POINT
(SSUed by: Date
C I .IO AT
si m,mreirA pee' memnmdo, a „e
Re -roofs
HAZARDOUS MATERIAL% DISCLOSURE
Will the applicant nr foam building rcrr,uru mom or handle hamNou, material
Type of Roof .
o dined by the Cuperino Municipal Codc, Chapter 9.12, and 111111cJdt and Sale”
Gala 0Yrr, 255Ja_l:'
a) uAr—
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or (mute building occupant use eyuiptnem or devices which
If a roof is installed without first obtaining an inspection. I agree to remove
emit haraudnu, air comaninars as defneJ by the Buy Area Air Quulry Management
all new materials for inspection. Applicant understands and will comply with
Di,h;e,"? ci
C1 ye, h
all non -point source regulations.
tds requimcn under Chapter 6,95 of the
I nave (cud the hwardoue nnncd mts
California Health A Sum) Code. Section, 25505, 25533 and 25534. 1 undarsmod,ba
if the building doe, not curently have a tenant, that it is my responsibility to notify the
ccupta of the m9nnamanu wl hman be rte, purr,, i, wan'o III a Cenlfeae of
°vrk ""y�
��11u1° �
Signature of Applicant Date
!%°e'er "'
All roof coverings to be Class "B" or better
Ownmmaumm tag—'