01030074CITY OF CUPERTINO
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CONTRACTOR INFORMATION:
BUILDING °'VISION PERMIT
HUILDING ADUHIiSS'. ��/�
PERMIT NO,
C>
OWNER'S NAME;
12: l20 2 S
C f fG'vR 'r7iJ
APPLIC ION SUIT DATE
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' PHONE:
SANITARY NO. CON 'I'ROI, NO,
ARCHI FECf/FlIG1NFER:
9�sJ)�
HUILUING PERMIT INFO
SLI% ELEC / 1'LU/N MECH
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LICFNSED CON] RACIOR'S DECLARATION
Description
1 herebyaffirm Ihm 1 ant licenwd under provision., of Chapter 9 (amhmencing
,lob
with Seclloa 70din of Division3ol be Has ,a,,, and Profess' C lc. ynJ mylicenm
in tome dlKt.
anal
L-cense / -!
ieen. Cl. x Ci
Dino �'�UI Contactor_ av Hidc,,�V
'
N UE
DECL/lNAT.ON
AHCHIll
I unJcnnnJ shy plan. >hull be ural ns public mcorJ.v
c a..
Liccnscd Profcaxional
OWNER BUILDER DECLARATION
I hcrchy thr..it had I a coop' from the Contractors License La, for the
following ..,I. (Section 7031.5. redacti anal Per c„ions Cole: Any city or county
whch 9 'to .I 'I Iter I J Ii,M1 p- y.11atre
pet I .uh 0 Ih pple hf hpe hie fl a J.I¢men'
that he licensed part° tt Ihprovisions fRec9lactor L (Chapter 9
Sy. Ft. Floor Area
Valuation
(enmmcnaln, with Section 701111 of Division 3 of the Buri tars .sed rood,ions Code)
or the, he is clooda therefrom and the basin for the of lager! exemption. Any violation
of Section 7011 S by any upplicam for a Nnint sublc'ce- the applicant to a civil penally
APN Number
Occupancy Type
of not mom than file nmdmd dnntr, (sun11.
❑ 1. as owner of the prnpeny. c r my o nployees with wages as their sole cotnpenwrnn.
Required Inspections
will Ju the work, and the slmemm is not Im,rI ,, ollood for nude (Sec. 7044,
Ivw due,
Rusin„ and Pmfuxsiunx Code: The Contractor's license rt apply m an
nworcr of property Who builds or improves Ihdmnn, and whit dates such work hineell
m through hk own anploytt,, pnrviJeJ that such Improvements are nob intended or
offered liar s:dc. If, howaxu the bnilJing or improvement is sold within one year of
ion, the owner-huilder will hme the harden of protan, that be Jia n., build or
iample
for pu,o C of ruled.
.mnmt//e
.'mn<r of the property. sen exclusively contracting with licensed contractors le
Construct the prolder (Sec. 7 ”. badness and Poic,,ions Cndu',t The contractor's
i,nuc I,aw due, not :ytply 19:m owner of pruseny won hall w improves Ihaeon,
and who ensure', for such pro}en, with a ocntmctorc,) licensed purWam to the
Contrader's laterite Law.
❑Ia mwnPl un _ _ 11&PC for this masonI
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v
Owner ,� Dam
'S COMPIiNSATION DECLARATION
I hereby mint, under penultyel Ile jury one of the following declnrnionx:
❑ 1 have and will maintain a Canidicne of Coss'° In .celLinsurc Rae Worker's
O
course,.Iion, as provided Ibr by Section 3700 0l the Labor Calc, for the
pclionnance of the work for which this peril is inened.
❑ I have and will mainnin Workcl'x Clonsco�uion Insurance. as relofrel by Section
3700 o1'the Labor Cudc, for tau perfmmamce of the work for which this pettnil is
Hued. My Workers Compensation Insurance carrier and Policy unable am,
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C urrieh:574YrdPu.,fv I'alicy No.; Z2ry.-OI-022L�'L3_
Cl?R 1'I19CATION OF EXEMPTION FROM W ORKI?RS'
COMPENSATION INSURANCE
(Thi, section need nM he vrontpleted if the permit '° for one hundred dollars
5100) or In,,.)
I certify that in the perfomance of the work for which this permit i, i,wcJ, I
,hull not employ any lw,.,n In any Inwmce so ax ,, heconm xuhlec't to ton Wnrketi
Colnpcnsation Laws of Calbrarnia. Date
A,or,an
Nuncr TO APPLICANT: If, tilde making this Ceniliaatc of Excnyninn, you should
Iwvonc xuhNct as the Worker's Cooperstown provisions ofth, LaMn Gds. you ani
fonhwihh cmnply with such provisions at this peril shall b, decahed revoked.
CONSTRUC'HON LENDING AGENCY
1 hereby Chir that dam, i, a Constmaion lending Iii for the aformmace
or the work 0n which This permit is Issued (See. 1097. Cie CJ
I<nda', Naum
.
[.carter', Add.,
I certify due I hate mad this'applicahion and state that the those inforatiwn is
correct. I agree ua cmnply with all city and county oedinanecs and same law, ral.du g
to building construction. and hereby authoriac reptescnntve, of this city m const upnh
ore anoto-menrnin vl propene rur inspection porpow,
-
Oscillate, m,secs indemnify and keep harlcsx the City of Criterion against
liabilities, judgmenu, Gnus aW dxPant,, which may is any way :seer.., a,uina said_
Cily in coa„quen,c uftl °milt, of this permit.
APPIJCANTUN 'R. SA.' WILLCOMPLI'WI'TH ALLNQ''sslI POINT
SOURCE r S �� AI
Issued by: r �' Date �
Re -roofs
signmam n pl If .n tae r,r Dale
IIAYARDOUS MAI ERIALS DISCLOSURE
Will he mare we handle material
wtani
Type O( Roof
Health an
e Cufahn o
is defined by the Capenino hdunicipal CNe, CM1tpmr 1.12, and Inc Health and Safety
ipal Cels. Chapter
Code, Section 25532fa1:'
13 ties CI No
•
All roofs shall be inspected prior to any roofing material being installed.
Will the applieantordrum huldn,ocoup.of use egnipmeltla.d,vic„which
If a roof is installed without fust obtaining an inspection, I agree to remove
emit Intonations air coria inamsasdefnod III Hay Arca Air Quality Mooradian,
all new materials for inspection. Applicant understands and will comply with
Di,nir,T
l E] Yes El No
all non -point source regulations.
1 have read the hazardous mmnrialk rcyuirenwnn, under Chapter (a95 of the
California Heahh & Safety Cu Ser mons 25505.25531 and ^--5514. 1 nnJcroand Ihm
ar flue nallmn, nosy nm NRC �aten teh:rrhl. mar'Il is my dipnMinihty to notify the
ccupam of the isms° h mu- be sen pail, to i.xasncc of a Cenilicne of
”
SignatureofApplicant Date
"B" better
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All roof coverings to be Class or
. owner, aaI °coca tg� Tine
OFFICE