01080087 CITY OF CUPERTINO' • t "' ft+"+' '
;.tlup,niuc DtvtstouPERMIT ,- CONTRACTOR INFORMATION:
• 'BUILDING ADDRESS, � PERM1IR NQ,.._
;- 18870 TILSON 'AVE14� ! JON `WILLEY '4 101080087
.:•._._ .T�._.;,,,,.,._.._..__...� .- .. .. APPLICPTION US DATE
LEY 1'8870-LTILSON"'AVE—— " " `"08/ 1'72'001"'-'"'"
PHONE: - - SANITARY NO. CONTROL NO.
n ce zARCHITECTIENGINEER� BUILDING PERMIT INFO
OF� L ELECT PLUMB MECH
z WU b I
z LICENSED CONTRACTOR'S DECLARATION Job Descrii76on t
S= ` 1 hereby affirm that 1 am licensed under provision of Chapter 9(commencing DEMO EXISTING HOUSE .
-
pv,f-J with Scaion]OUp)of Uivision3ofthe Nusinessand Professions Code.antlmylicenu
m I Is in full force and'effcar'
s i a K Lice se ClassLic,g Ua1Cn 'r , Coppac., _
ARCHITECT'S DECLARATION ,
u to 4
yI understand my plan shall be used as public records
sh $
to a p 0 Licenud Professional 'I tis' It t % •1 '
n OWNER—BUILDER m the CoATION •, . . „(„ ;'
. Ph by uISce that 1 .exempt f the Coamno . Lc Law fur the "
at
following on.(Seer 7031.5. dP sessoli Cale Any
maran aor,prty•
E O which y p l m conamn aIle p dem r,h p t any aructurc
cc3 Prot ¢ olem am for such penmti file signed mntenl 't'••1'
that he rnsed pun ub dlep a. saf the Comracta LF le IChapter9 .-sQ,,��( �j� r,,k�a Valuation
(con u'd, ab
.Lima 1000)of OVlston J ofthe Busine. d Ptofcavons Call i 3 rl-7LL`iQT�• CJ`!1"
or Nat be is esempt therefrom and the boas for the alleged cicmpuon.Any s'iolmion
ofSoction 7031.5 byany applicant for o permit subjects theapplicant to a cml Penalty _
of not motetM1asR,o,W bod!dollars b5001 NO AMNgNll INSPECT ONS ,, .Occupancy Type
°L a,owarrot th p peny.carY em,h y th wage,III compensator, ..,
will do the k' hJ the t t re- s , t t d d Wofford for sale(Se=.]Et4 "' - '^ • • -
Bu sn,ddrof8ss,ons Cai he Coal me.....Loean Law dries not apply,ran .. .,_...-. _—. ...... . Inspections.,.. ..,: . ..._ ..._--_-_-,.,.------
,.
that ofh his ow Who builds or Improves thereon,and who eats such work himself _.. ... -
or through his awn carplovess, ended that such improvements are wt one sM or _-
concd fasale.If.M1owc er:the wilding or imPmvement n,mkt within one yen of •rf s .•,
ampler th o wldc will Wo,the w,:le fp gib thcEtl nor Wild or
Ma'
f pry:. r ) Y`
1 f�M1 p pe tY .1ly t t 8 tr with fee uJ co caano
short thep j t(5 7(44 Business d P f '- x C 1 )Th Contractor's
,
Lic L J t apply t I property h builds improves thereon
.and 'h c mmm f r ch projects with ontacmns)Ic sed p rsan to the
Contractors License
❑I am escapist under See .B&P C for this re on i
Owner�`�^��"� /y� Date
.W(/ ORKER'S COMPENSATION DECLARATION
• ,.� I hereby affiria rpiIc,,cnqli, 1 laerjmy one 1 the following derdapaimot . , ..
❑ 1 h e ad still ma nu ir Ccofflahc of C sant as aciff iname for Workers
Compensation, as provided for by Seen.. 3700 of the Labor Codc, for the , •It ', _ tit,,,' •
Performance of the work for which this permit is issued. •�, t �, .. t
°I have and'wit]mai main Worker's Compensation Irtwmnce.as rc4madl by Section
pli - Permit „ l: a 1,•. ,..< •. '„ .1
3]Qf the Limit Cool f ,I 1 rm of
'
issued,M W k r'eC' pe :'t ml .ur -ad Robe,minter are:
n�for which m, t to 1
Pufcy'No. u.',•..s st.,+ . L .' ). s.'- t
CERTIFICATION OF EXEMPTION FROM WORKERS':'h - —
,i , fl �y,a,COMPENSATION INSURANCE
(Ibis secban noed not bs compleud if the pcant is for one hundred doll
(SIM4 )
Itt ufydrfin[he pef ' fthe mlkh hilt pc'mt' ke.l
'hull not employ a,pc .i
n t,' ,y iia me st by os to heroine odjerdha tM1c wororkers .. .: _.-._ _ .._ _...._., s ..,a,. ........ _ ... ,_. ... ...... .,... ..,...
aw,if Crilturar,
Adun to the WbrVeIS CO Date:
Applicant
„ r.... . ,..:.. .
NOTICE TO APPLICANT If Bc,ra.lki.I Certificate of Escamptim.you should " t •' r
- 'z bee comply
mpenmtpro hoof ihelzw Code.you must
O forth tit pp ly with M1 p ns.or this pc t shall bmM
e do inked
O .
^.U0 '• CONSTRUCTION LENDING AGENCY '
Ibl Ifrn1Irt,t met i dig a6nyf Me perfrmaaax
o
ofth kf 1 chth p l : ssacd(S 3U)] Civ.C,
P, ^ lender's Name s.. .. .. .. .. . _ . . .._
P,
Lender's Address - - - --
V OI ccnifY that l ban.read this application and sutc that the above information is
m clorren.I agrtc m amply.with all city and county ordinances and state laws relating
:O tobur lding cohowetion.and hereby uuthorim apreuparbacs of this city to enter upon
the above mean a.pmpco,for Inpcaimn purpows., 1
-�,p, (We)agrecto save inlcnniry unit keep harmless the City of Cupeminn against
h Imb'1't judgmenn. s J expenseswhich aY,in;my y'c Ie again said
V Z Cit ho c c,lence:f the eponfingofths pcmaii.' /p
APPL NT UNDERSTANDS IN D WILL COMPLY WITH ALL NON-POI Y'T
�7 Issued by: Date
5Piss
Aj5 '000
Igo, eol A,pfi.nYCwmmrm, How RE-roofs'
HAZARDOUS MATERIALS DISCLOSURE 1
W,11 its, ,,ream or ft Wilding ac pat tore we handle liumdous matad:[ Type of Roof. .' --
ns defrcE by the Captain Mraniepal Curie Chapter 9.12,.,,it the Health and Safety ,.
Coda,Se i on 55320 1 p. 1•,1 ,
,,z ❑Ye: .o Ivo1 - --All roofs shall be inspected prior to any.roofing material being Installed.
• evilm appy= t r t wild g w 1 'i p t e hotm If a roof is installed without first obtaining an inspectmn_,_I•agree_to remove-
m
ethazardous air ciarmarimpr%as defined by the bay Aa Air QualityMaimagicareml,
District? -all new materials for inspection. Applicant understands and will comply with
°' i. °No . all non point source regulations. '
I havesrcad the hmarJous mntcrialv�iegbir emu ban enter "'t the
CuLfBmlu Ifealth&Safety Code.Serious 25505.25533 vad 25534.1 underot tw1
'if bet,iIding does not cur7cMy bare a enan6 that it is my resj»nsibiliy'to notify the'
ac am of the rcquircments which must be ma prior m issuance of a Cenibco¢of
of cupanc
)� Signature of Applicant _ .,. - _ Date
o~' amm�damagrnt„ - Date All roof coverings to be Class "B" or better'