00060172 CITY OF CUPERTMO
Buu.UWG DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDINGADDRESS:
PUMI'INO
10363 SAN FERNANDO WN H FRY CONSTRUCTIIN
OWNER'S NAMU: APPLICid[ON Suit DATH
FRANCA & N.
PHONE: SANITARY NO. CONTROL NO.
m X00 ARCIIIT[C'rIENGINIiIiR: BUILDING PERMIT NFO
❑ RLDQ IUTCI' PLUMB MECH
N IiW I_1 I_I I_I I_I
o -o sects
70h))of mmlalt3orbe11nna..praNsiumo(r,Code,amInnnenense .lob Description
�ytw withfallf n)Ulid of Divici�m3nf the lluxincen and Pmfcnninnx Code,unJ myliccnne
in fall lass anJ.Rens
s s< i.i.ent.Class Lie.« DEMO
Date Comma...
u 3 a. ARCHIf EC'p'S DECLARATION
i� 1 unJcrxumJ my plan,x1,11 he rasa m pub io IccuNx
c,
w EO Licenwd protJssiunal
oa OWNER-BUILDER D11CLARADON
=+m I hereby of iron that I am exempt from the Contractor's Licence Lam for the
I following r[ ant.(Section 70(11.5.Bonne..and 1'ntfc..i..m Cute.Any city oo,oan,
pe
which requires a rmit to c a
onuct,alter,improve.demolish.m¢pair any saucier.
u, pdnrwhslswmnec also re"me,ahca"Ifi,tnt fur snclys'aii m tilcvsigncA.Imcmcnt
5— 'hat w is licensed pursuant it)the provisiono of the Commelitex Licen,i,Law(Chapter 9 Sq. Ft. Floor Area Valuation
(.onnnmuch,with Secl fnn'TXM)of Uivition 3 of the Rosin—mal PrdeWions Coder
or that he is exempt Ihemfrom and the basis for the allege)ean+ptioo Any violation
of Section 9031.5 by any appl icon,fns it pcmtit subjects the applicant)v civ 11 penalty
.1 tmore than live hundred dana..ts500) APN Number Occupancy ype
C1L,,owucruf l lie prnpeny.it Illy cn,lo,ce,with wages on their de ce ifinsxllon. 9 7
rill Jn the work,and the structure is not intended or affercd Int sale(Secs Il94, -
Brnxiares,and Prrv%sien.Code,The Contractors Liccaxc Law dues not apply m an Required Inspections
)wnet of pmpeny,who Haim%()I hnpro c.dmourn.and wbo dress such work hlnuelI
or through his own employee.provided than such imp wcnmnas am not intended arsINSPECTIONS
uttered sur m1e.1f,how.,[,. he I ildblg ur impro,ca co,is sold within one rear ur NO ASSIGNED
completion.the axncrbuilder will hmc the Muret of proving that he did not build nr
mpn clbr purpos of sal,
y� %tmcl C
r of the pore ny,am esclwively contracting with licensed contractors to
License the project(se. loan owner xs and Pmfnssiom�Gale:)The Coalrucmr.
License Law tact not apply loan Owner of t, onus who Mums impm,c.Wereun.
and who ammlaens For such project.waab na tamaa.mnxl licensed lhuisinlit m,t.
Cnmrur ew License Law.
711 our ex/e�mpt un�do'/Se .❑kPC far this lemon '
OwnerDane • `'
I WORKER'S CONI ION DECLARATION T
I lemhy alllrrt under penalty,.perjury I of the fallowing dacbemians: - ✓ 1
C 1 h 'll nimoon r( ane 1 Consent t df . re f Workers
Comps f n u p s d J h byy Set 3981 f the ].an,), Code. I he
perlil � f theA w for which thi, .Iit ed
01 have and will maintain k k .ConaNturnion Insurance,as required by Section
39x1 of the Labor Code,to the pet fonron.e of A e work It,,w1 ch this punt is
issued.My Workers Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CER1IPICA'1'[ON OF EXHMPI'ION FROM WORKERS'
COMPIiNSAI'ION INSURANCE
f I1Js s<ni....aced nm ne.a+mplcmd it the permit is It,one I...aded dollars
(1100)nr Iu.J -
I cenily that in the performance of the work rnr which Wil ryrmit is issued.I
shelf not employ any person in tiny manner w+as u+become subject to the Workers.'
Cn a,nsa,ion law.nt Culilnrniu.Dmc
Applicant
N01®r 10 APPLICAN'11 11L alloy nuking this Cceia7cum o1'Exemption,you should
become subject to the Workers Compensation provisions of,he Leben Cale.you must
Q O tunhwltb comply with%mh pro loons or this permit shop he deemed revoked.
CONSTRUCTION LENDING AGENCY
s 1 herchy vflinn tbu there %.......ametion lending agency hs the pn lbrnunce
of the work for which this permit i.issued(Sec.3097.Co,C.)
Z Q Lnmcr'..Nora
Z Lester',Addmss
V 0 1 certify that 1 have read this application and state that the uMrve'uanmatiun Ls
k, F„ correct.I agree to comply with all city and county ordinances and stale laws relining
Q f) to Wilding mourucaor,and bemby u,thuri,repr"alati,es of Obit cry m nater npna
} the allow..mentioned property for inspection punitive,
�•' y (We)ugive m se, ndlanifr and keep harodew a he City of Copeman against
to Iiabilitia.juJgmcntc cava and cape,...which Inay in tiny way seems agaimt.aid
U Z city m[an.eginea.•arm.sraitnng of mit per,it. _
`� APPLICANT UND'RsgUWILL COMPLY WITH ALL NONPOINT Issued by: Dale �o
S UHCE R O
:'gnmurc of ApplicanVComm[tor Ute
Re-roofs
IIA%ARile.Wilding
IALS DISCLOS.IRE
worntheCo,emorrmurcwimntoe,Chaptm+morlunAeHevdaandSafety Type of Roof
at d,Sex by the .120)?no Mnnicirynl Calc.Chapter 9.12,and the Health aril Safely
Gmc.Sectinn 2553$v):'
❑Yet 0N All roofs shall be inspected prior to any roofing material being installed.
Will the applicant orfuum Wilding occupant use equipment or devices which If a'roof is installed without first obtaining an inspection, I agree to remove
it Ievtar
,Nons ......ti a u,a,defined by the Bay Asn Ar Management
Quality Magement
•,nnlatn[rl all new materials for inspection. Applicant understands and will comply with
❑vex Cl No all non-point source regulations.
I have mail the hazardous matenulk mgniremems under Chaplet 6.95 of the
California l leolth dB Safety Calc.Scmioat 25505,25533 and 25534.f undenaimd tam _
if the building docs not curremy have v tcnam,that it is in,ne"a sibiliy to,old,the '
ceupum of the rcaaim ,ems which umm Iw tact Aria.o-+i"..In[c ora C.niram of
Occupan`y.. Signature of Applicant - Date
i ,.anmuneedtisent Dat. All roof coverings to be Class "B" or better