00110078 CITU OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING AU))�I_i 71a SCENIC BLVD rI:RMfr NO.00110078
OWNER'S NAME; APPLICATION SIM DATE
HOGG 1. 1 /14/2000
PHONE: SANITARY No, CON I Hot,No,
M ARCH]I EC17ENOINEER: BUILDING liRM1'IINFO
O U BLIN3 ELECT PLUMB MECH
F G CI I_I CI Cl
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r y LICENSF,D CONIRACTOH'S DICCLARATION fob Description
Z y�_" 1 hereby ul'finn(hal 1 ant kenwd under provisl m,of Chulner 9 ror n a ing p
O-mI-I�Ji wilhlcclion 9111M11of Uivi.vinn Sof the Imonesad lrml'aneio Cudgm,d u,y licnuc
a-- i,in fillforecamle'if",. $ 7VnsQit GASLINE/FIREPLACES
6 Licen. CI I,s Lic.q Q
r o i u Comnaor
3 u.F ANCII I—'S DECLARATION
t_a tin 3 1 undenland my'].'I'shall he used as radii
I
C ce O Licenced l'a,l'cneionul
a.
n'S o OWNI!RtBUILDER en dhe NATION '
I herehy.(lien,on I nm exanpl from the Convns Cos Licenm Line for the
foilowing fere%u Permit
to]IIJI m,BndneImpro e.eslo demolish.
or repair
city or county
_S es which ts e,mil I n Imrepalter. p do \M1 p' y.l wrc
i 3 es Poor I I a also y p applicant r n Permit I is signodstatementer
mann licensedpursuantl m p m iso Contractors tress
1 (Chapter S Ft. Floor Area Valuation
'1�T
or th 6 'nhSen ]IXNp IUsir J III l,,vio dP ,Ieavone Cute) y ti�.It00
or mal he is 31.5 l anyemr"I.ore he noel, l din a the 'Tai no any Viomaun YJVJ
If f a,),mo J1131sby nnydred um to,apa,mil sunfmn me applicant mucivil pamJty
ornon mom mall fi,enanarea alawtslxsaB. APN Number ccupancy Type
❑1,as owner of the and
the y,or try employee with w'o r o e their ossa amSee.7aon.
35708022. 0171
Is Bill ne the work,and,M1e ammum is not torsintended e offered for salt(See.]pals
Business and rmfu.,ioms c,de The cummtmrs License Law J«.'not apply to an Required Inspections
of pi Who build, ,,in,rm,e,hereon,ant who does such work himself 202 — UNDERFLOOR PLUMBING
.Ili 1, his awn employee.,pr.v1111iThal such ian ems ore non mended tat
nrllercd for sale.IL howe're,III,hnildin,o,imp....Icar I, ,,fit wllhin one .or of 301 — ROUGH PLUMBING
isold,noo,the owner-la ilder will have the harden i,l p nsin,mm he fidnot build or
mproveJim ya,weofwley 502 — FINAL PLUMBING ENERGY.
❑1.a,owner ofineprop.ny,anmexcm,ixelyconnmctin,wimlicensed enmmaumto 506 — GAS TEST
,tubi me P,,,j.t(Sec.]113,Business sad Profession,coni He Comrvetor'.
LiicenseLawdoe,not apply ,,anowne,nf,an,ii who huildco,hopmve,thmcam, 507 — FINAL PLUMBING
and who ..mel, in such m'oell, will a.mnvn s') li,,nwd pn Its'a,the
Cnnl...or', acoo,Law.
C l amexnnpl under Scc. ,B&PCllnlink mann
Owner Dam
WORKER'S CONIPCNSAI'ION DECLARATION
1 herehy apir under penally o(pojuryuncofine follewing dee mlion,:
'0 1 have and will maintain a Caeilicae of Consent In nelf-inourc for Worker's
Conscroation, m provided Int by Section 3Il0 of the lalnr Code, for the
performance nl the work far which Ihi,N:nnil i,issued.
C I have and will maintain Worker's Compensation Inwrmce,as required by Section
39x1 of the[.shot code,for the pertur n ince of the work for w a,li this wrmit is
i..ue_My WooArer�s ConIywu,rfl(n�Immrmee carrier and I'nllay nwnMr are
mi
Cacn 5T-. 7� policy Nn.: � 177.rf
CHRIIFICATION OF EXEMPT[ON FROM WORKERS'
COMPENSAHON INSURANCE
(Thi,section need not he completed if the Nook i,for one hundred dollars -
ISI W I tar Tess
1 certify than in me performance of the work to which this panni)is issue.I ,
shall not ennp(oy am'perw n in any manner so as to hecome subject to the Workers
Compensation Tons,of Califoul Due
Applicant
NOTICE TO APPLICANT:It,aIle,making his Cunilicae of L,i ion,you should
become x,,hje,t m the Worked,Compensation pow,a nc of the LaNa Crdc,you mu,I
Ofoothold.comply wish wmh pmvloon,or this Permit,hall he deemed rI...ked.
F ^ Chat heNUCIIONLF.NDINO AC,Iagav .
NCY
I hemay which his era iss conn (Sec. leading1C a,evcy for the performance
of the,v N fur which his pemm is issued(Sec.3W 1.Civ.C.)
P. Q Lcmal Name
Z Lender's AJArcns
V [�Y
11 ohm I have nvd nhia xpPlicalinn unJ nbau ohm the above ol'onuwinn i,
Rs til fi Reel.1 ain't:In Is Illy will aB ally and enrmly vufi1vu1C,and Mlale all eclming
Q V ,I hinklin,aalorefinn,and hereby uullmrirt tepm,mromive,at this city mance.Nm
the above-nwn iomed pmpeny ror vopechmi ru,"i
F„ a INrel agree to save,indeumily andkeep harmless the City ofCupenino.,also,
VI fall ems,conn arm ex n,es which may' m
in any xa,ace uImino said
U Z sky- aonwquc cenr the grmnn oflhispermit. r 1.1 ANTt� l'�
U DERSTANDS .U WILL Issued COMPLY WITH ALL NON PO Idb Dates 1` —\
cr REc I,nrlolvs, �— /1/��//p,� y' .
Sfgtmmm o names mo. or / Dale Re-roofs
HA ARI OUS MATHRIAI ti DISCLOSURE
tappkcar mmlumWil(tins«eupant,tommhmdleh..amllm,matenal Type of Roof
I,,dm in y tl¢CuN inn Municipal Cede Chapmr 4,13,and IM1e Hvnl,h unJ Safcry
Cee,Section 25532(a)'I
OYea 0 No All roofs shall be inspected prior to any roofing material being installed.
Will meapplie:mlmlnmre hoBdm,ocanp:ml use ouipmenl oe device.which 11'a roof is installed without first obtaining an inspection, I agree to remove
n haaarJun
ous air conminunas defined by the Buy Area Air Quelily Managen ual
.uminldCR all new materials for inspection. Applicant understands and will comply with
0yr, 0N" all non-point source regulations.
1 have read the haaanln I,materials requimmeme under Crane,695 of the -
Cniifmnia Hcallh&teal 'ole.Snlinm 25511,,2 .33 and 255.3,1 undunend mal
iflhc hnlldin,dnch son 'h:lvealenunl,Ow lis my recpunxihlllty ar notify the
mo"uml of lac Rents+,h anal M+me prior In,wam a of a Ccmili,,a of
,our""`° Signature of Applicant Date
owwr-1 mduriaed o ems use All roof coverings to be Class"Bfe or better
OFFICE