04040156CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
I:� aWaUZT01 INFORMATION`"
BUILDING ADDRESS:
WILLIAM NANCE
PERMITNG04040156
18965 TILSON AVE
OWNER'S NAME:
PERMn ISSUE DATE
WILLIAM NANCE
18965 TILSON AVE
06/22/2004
NE:
SANITARY NO. CONTROL NO.
HITEcroaRGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hareby amort that I an lira d miner Provisions of Chapter 9 (commencing
wide Section 71)(of Division 3 of the Business and problem. Code.md my license la
in full fame and affect.
1 -STORY SFDWL (2124 SPACE)
Cline uc.x
Dow Quantum
Dam
.SQ.FT.LIVING
GARAGE 564 SQ.FT.
ARCHITECTS DECLARATION
1 understand my plans shall N wood as public rumNs
Licensed ProlesYoml
OWNER -BUILDER DECLARATION
I herahy oBirm that 1 am exempt from the Contractor's Limnos Law for the
following moron. (Section 703 1.5, Business and Profeaanns Cade: Any city car county
which requires a pmmit to c sac cl, after, Improve, demolish, at repair any sum ium
prior to In Issuance. also mqulmJ dm applicant for such permit In rile a signed statement
that be is licensed pursuant to the Provisions of to Conuxmr's Liam Law (Chapter 9
Sq. Ft. Floor Area
V""o00
(commencing with Sermon 7010) of Division 3Ofthe Business coal Professions Code) car
that he is esempl therefrom and the hula four the almgW exemption. Any violation of
APN Number
Occupancy Type
P y �T•)p
Sudan 7031.5 by any applicant fan a permit subject de applicant to a civil penalty of
not mom than five hundred action($500).
37510061.00
in 1, u owner of that property, u my employees with wages u their sole compensation,
Required Inspections
will do the work. and theaorcht.hut intended maRemdmrmle(Sec.70al,Business
and Professions Coes: The Contrume, Llanee Low does IMI apply m an Owner of
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property who builds car improves thereon, and wha doessuch work himself orthrough his
awn employes, provided then such Improvemaneve cool handed croffmW ferule. If,
howavu, One building or Improvement is mid within one yon of completion. the comer.
will have the burden of proving that h did not build m improve far purpose of
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nll�►LE
1, as Owner of the property. an excluively contracting with licensed contracters to
construct the project (Sec. Trial, Bmines and Pmfeeslons Cade) The Contractor's LI-
ume law does not apply to an Owner of property who builds or impmm anemone and,
who anuacu far tuW project withacontnctc(U lmeoulpunuantmtheConuactoh
—
MAY 2005
L nse law.
lama pt under Se/t . B dt P C for this moan
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s WORKER'S COMPENSATION DECLARATIO
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I hereby arrow under pmWty of periory one of the following declantiot:
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have and will maintain a Certificate of Cement to self -insure for Wokafa Compen.
. u powidea for by Section 3700 of the labor Code. ro the perrarmena of the
for which this permit is Issued.
❑ 1 bases and will maintain Workers Compensation Insurance, u required by Section
3700 of the Labor Code. 1. the performmce of the work for which this pemmit is issued.
My Worker's Computation Insurance carrier and Policy number arc:
Canter. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
rihissection need nolhecompkmd If the rend, is franc hundred dollars (SIM)
or less.)
1 retry that In the performance of flee work fm which this permit is luted. l shall not
1 loyany person in any mannc�wl t�bpfmrAubjut to Warken'Compesagon
Laws of Calif sofa. • / / fr//YY
Appllant
NOTICE TO APPLICAN . IL after making this Certificate of Eumption, you should
became subject in the Worker's Compensation provisions of the Tahm Code. you most
forthwith comply with soh prnvhaens Or Nis permit shall he domed revolve.
CONSTRUCTION LENDING AGENCY
1 hereby drum deet them is a construction lending agency for the performance of
'
dee work for which this peanh Is issued (Sm:. 3097, civ. C.)
Lenders Name
Lender's Addmu
I certify the. I ban read this application ane sum Nei the above Information is
'
cannel. 1 agree to comply with all city and county ordineact and tum laws totaling an
Wilding construction, and hereby authorize represenslivea of this city to anter upon the
above-mendamed property for impemion purpose.
(We) agree in an, Indemnify and keep harmless the City Of Cupertino against
Ilabiligee, judgmene, cases and expenres which may in any way acme against said City
I. conmgmnee of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGU TIONS.
Re -roofs
Type of Roof
Si alure of ApplicanUContncmr
HAZARDOUS MATERIALS DISCLOSURE e'��
Will the applicant or future Wilding scup rmstore or handle haardous material
as darned by the Cupertino Municipal Cam, Chapter 9.12 and the Health sod Safety
-
caes. o an 25532007
All roofs shall be inspected prior to any roofing material being installed.
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a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or wwto building output sura egmpment car devices whichIf
It hmardous air contaminants u defined by the Bay Area Air Quality Management
all new materials for inspection.
ict7 `/
Oyu ITN.
I have most the haardmumamrials rcquimmemo under Chmumli.93of the Califor-
niaHaide&Salctycade, Sctimu 25505,25333.w 25534. l understood Was irk building
does at currently dew • mnant. that it is my rcspotihilily, to notify the occupant of the
must W met prior to issuance of a CmtiMam of Occu'cy./'yg
rcuiulrc'r�ac,((aanl•//}a
Signature of Applicant Date
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All roof coverings to be Class "B" or better
owner L
car author J e I