01020045 CITY OF CUPERTINO
BUD.otNG DIVISION PERMIT CONTRACTOR INFORMATION:
BU1I.DING ADDRESS: [TERM]r NO. 1711020045
22820 SRN JUAN RD �Af
OWNER'S NAME: APPLICATION S&
TOM
TOM HUTTON VJ
PHONE: SANITARY NO. CONTROL NO.
Mai ARCI III'ECII/ENGINEER: IIUILDING PERMIT INFO
w O O H DG ELECT PLUMB MIiCH
G j LICENSED CONTRACTOR'S DECLARATION
Z"' Ihrrthy,IdcnWatlnnnlicensed under pnovi.ann.mCleaner olrmttmro,in, Job Description
�N=o
cm wiNSedinn](XXrynrDivisinnJnflhedminrss;mdl'mfessiansCrNe,mdmylicensc FENCE PERMIT
S--I is in lull l imam and c11 cl -727-111
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C O i U Liccnw CIq) c_zl Lip,a ��{ .
Dmc�s Q Rmormona ,y
LL� / `— lu 1—=S DECI.AR, {-QtIG
g I underat nd soy plans shall he nxd ns public.ecoeh
O�O hittv.ed I'rnre..innul
'm OWNER-BUILDER DECLARATION
vl m 1 hereby affirm that I ant exempt trent the Connectors License law for the
following mason.(Section 7031.5.business and Professions Code:Any city or counts
Fo
which I pconi,o to....wracialler,inprove,demolish, p Y solarium
3
priorto itsL 4 the IPI' nt for suchformal He a vogned statement
thin or liccowdpursuant Ithe powroitas ofth C n f ecseta (CM1 pt r9 Sq. Ft. Floor Area Valua i�ry���
pa g wnh Secoon 7000).1 Dtv +t Set the liuJ e ul Protest. 1 Code)
or that hemis exempt nhereliam and the basis for the alleged exemption.Any violation
of Section 9031.5 by any vrdicaol for a pencil subjects(lie applicwn to a civil penalty
nrnot more than rive hundred dollars 0300). APN Number Occupancy Type
❑1......coitime n.mm lams with woe.a.their.rde pans 1h,n. :34221025. 00
pmpp r remr y g tensa
will do Ib
nwork,and Inc structure i,not intended' or oleted for sale('Spey]1WoL
covid
Who ReHaedBUlpp1�tdm rte ad I rms rheC Iras,, i 1 x J+ t rely or mor
I I+e nt illsimproves thand tit such S1E — FINLofdugh: employe. .....do suchnp it ttended
ofenal 1 If nice, tin building or P e t sold lin y of
completion. ine p liec will have the haden almoving than he did u t huId or
improve for rarn,seofsme.). g1 1''Nqqggti��
❑Las owner of the pmrpey,am evdiae,,.nrmmcting with licensed contractors Conant nan u 1
mecow I a%does
(apply to n Bo urr o sad Proerly thons GsIor improves
nes Remain, /
License law dies not apply a on e's w of pmpedy who builds or Impm,ut thereon, it; /
C.Ind who co;dntem Rn snch Pmjeels with u vonm;mmgsl iicunwd pumnam m the
onte nrtvlin le law. �J
❑I on exempt Dolor Sec. ,d&P C far this rtmnn
Owner one
WORKER'S C'OMPENSAI[ON DECLARATION
I hereby al'linn under coalty(it pahov one of nine I c1hoting dednmti'o.
O I have ;uta will nn;l;nam a Certificate of Coneetn m"If-insure rnr Worker's _
Cnmperowinn. as provided an, by Section 391X1 of the tabor Cade. for the
Ietl'antoom of Nr wed ba which ml,prnmit is isancd.
Sf tmve and will;unimnin Worker's Compensunit)n Imunnce,as requited hY Section
39(X)nl the Tabor Code.for the led'nrmmrm or tlm work for which Ibis recoil is
.used.My Workers Cota,,}crnr�%aatioa Insurance carrierandPolicy number am: -
C'orrirc. P�R I)'ll '1'ION OP IiX[MI'fION IItO'1Jt.)D L
COMPENSATION INSURANCE
(This wet i need not be mradeted if she perm..is For enc hundred dollars
(SI O(0 ur I1.1.)
I cenily Not In dm perrnemnter of the work for which Chip Permit is:%surd,l
shall nnr employ any proven in any manner m as bt benmte subject ut the Wodery
Cumpam.fi i Laws of California,Dal
Applicant
NOTICE*1 O APPLIC NT.IC after making this Ceeifcme of lixemotoo,You should -
bemmis suhject In the Worker's Cmnaarsmion puts unv of the Labor Code.you roust
Q Q Innhwith conicity with such provisions or this permit shall he daemN mwkeJ.
F ^ CONSTRUCTION LENDING AGENCY
I hmdry allino it,,,them i,a com,ration Is fin,agency for the Pcrfnrnu om
w ar the work for which this .it is issued(Sec.3007.Civ.C.)
6. Q Lender's Name _
7 z lacrdcr's AJdre,,
V O 1venify that l have nmd phis application and.state that the aMve filormation is
Iy H p+rren.I ngmi,u+comply with all city.,to cnnmy ordinances and.late Inas relating
Q V .n building conslmplion.anti hereby authurw representatives or this city In enter upon
ry] the above.mentimted pmperty he inspection purrs'. .
G [Woo agree to nave.indemnify and keep harmless be City or Capetian uga+n.t
i. V) 6.0halhics,judgments,costs and expenses which may in any way accrue against said
� z
;Alylo,
ICANr UNDF AN AND ILL COMPLY WITH ALL NONPoINTk-dw>cu ,nt Issued by: Date
;r a. ttcammrmr Dane Re-roofs
HA]ARWUS MAn ER1ALS UISCLO5URli
Will,rte;eCtopammmwn:ap.1CgaapaptNomahatttheHelthaslamcdw Type ofRoof '
as de.SeJ by the 320)fnu Municiral GWc Chapter 0.12.To it the IIc;Jth arta Safety -
Code.SLpctiem25512(uY' 0 N
All roofs shall be inspected prior to any roofing material being installed.
Wil l the apdimm cr I clop bottling mcupam ase coluip;nent or dev ices wbich If a roof is installed without first obtaining an inspection, 1 agree to remove
mi.hnardnus air contaminants m defnN by the 11,Area Air Quality Management
auiHr+a9 all new materials for inspection. Applicant understands and will comply with
❑Yes No all non-point source regulations.
1 have read the Iurallom tnamrials re,Wrements ua&,Chapter 6!95 of the
Califnrnm Health&S:day Code.Se.....25515,35533 and 25534 1 undcrsmnd that
if the building des net currently have a mount.that it is try respsirshil'ny to nerdy the
ropwI of Ne teynioaneats which nuot be met prior to issumm of a Certificate of
°Cupanory' Signature of Applicant Date
owner
or
altthmi,<l ages. Date All roof coverings to be Class "B" or better
OFFICE