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NO PERMIT NUMBER X1114 7867 , INSULATION CONTRACTORS ASSOCIATION OF CAl1FORNIIIANC. P.O.Box 13482 • 1900 Point West Way • Suite 120 • Sacramento,CA 95813 (916)929-2275 S IS TO CERTIFY THAT INSULATION HAS BEEN INSTALLED IN CONFORMANCE WITH CURRENT ENERGY REGULATIONS,CALIFORNIA ADMINISTRATIVE CODE, TITLE 24,STATE t OF CALIF NIA,IN THE BUILDING LOCATED AT: T n /TRRAC)T x STREET -Cl TM��,L/�Qfh �G.r� EXTERIOR WALLS: 7— '� � � R MANUFACTURER THICKNESS/TYPE VALUE_ CEILINGS: BATTS; MANUFACTURER © � THICKNESS/TYPEL// VALUE BLOWN IN; MINIMUM R- MANUFACTURER THICKNESS VALUE SQUARE FOOTAGE COVERED NUMBER OF BAGS USED FLOORS; R- MANUFACTURER THICKNESS/TYPE VALUE SLAB ON GRADE: R- MANUFACTURER THICKNESS/TYPE VALUE TH OF INSULATION INCHES NDATION WALLS: R- UFACTURER 9 'q -THICKNESS/TYPE VALUE GENERAL CONTRACTOR-- CALIFORNIA ONTRACTOR_CALIFORNIA CONTRACTORS LICENSE u DATE SIGNATURE TITLE INSULATION CONTRACTOR CALIFORNIA CONTRACTORS LICENSE's 17 DATE S TURE TITLE f _� Sheet '2' L ' •I:ITY OF CUPERTINO BUILDING PEP. Permit No: \ Address: 777 _ Date: — J BUILDING PROJECT IDENTIFICATION WORKERS' COMPENSATION DECLARATION r �� I hereby affirm that I have a certificate of consent to self-'in Applicant's Mailing Address � �"�`�/' sure, or a certificate of Workers'Compensation Insurance,or a certified l� pj� Cd• t copy there Set ,rP b.Y � Address of Building Policy\ man P A ��� Certified copy is hereby furnished. Owner's name Certified copy is filed with the county building inspection Telephone No. department or county department. Contractor's Name G• Date .Applicant Contractors Mailing Address .f. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE ic. N . (This section need not be completed if t�a permit is for one 'Architect or Engineers hundred dollars ($100) or less.) Architect's or Engineer's Address 9 /QS((/Yj'-1�• I certify that in the performance of the work for which this permit r Lic.No. r(� is issued,I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of California. LICENSED CONTRACTORS DECLARATION Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of 1 hereby affirm that 1 am licensed under provisions of Chapter 9 Exemption, you should become subject to the Workers' with Section 7000) of Division J of the Business and Compensation provisions of the Labor Code, you must forthwith Professions Code,agIibmy license is in full force and effect comply with such provisions or this permit shalt be deemed revoked. License Class Lie. Number Dale — — Contracto L CONSTRUCTION LENDING AGENCY /v 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit_is issued (Sec.3097, Civ.C.). 01VNER-BUILDER DECLARATION Lender's Name 1 hereby affirm that 1 am exempt from the Contractor's License Lender's Address Law for the following reason (Sec.7011.5,Business and Professions 1 certify that I have read this application and state that the above 1 Code: Any city or county which requires a permit to construct,after, information is correct. 1 agree to comply with all cit • \, improve,demolish,or repair any structure,prior to its issuance,also g P Y t and n,county ordinances and state laws relating to building construction, and a requires the applicant for such permit to file a signed statement that hereby authorize representatives of this county to enter upon the he is licensed pursuant to the provisions of the Contractor's License aboveK entioned property for inspection purposes. Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) or that he is exempt therefrom and Sign-tare of Appb.t or Agent r the basis for the alleged exemption. Any violation of Section 7031.5 ,Ds1p by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500).): - ❑ 1,as owner of the property,or my employees with wages as "OWNER-BUILDER VERIFICATION their sole compensation,will do the work,and the structure is not intended or offered for sale (Sec. 7044, Business and Professions "Attention Property Owrer: Code: The Contractor's License Law does not apply to an owner of - was 'An 'owner-builder' building permit hbeen applied for in property who builds or improves thereon,and who does such work your swine and bearing your signature. himself or through his own employees, provided that such "Please complete and return this information in the envelope improvements are not intended or offered for sale.If,however,the provided at your earliest opportunity to avoid unnecessary delay building or improvement is sold within one year of completion,the w ocessing and Issuing your budding pert ir.No building permit owner-builder will have the burden of proving that he did not build svi 1 be, issued until this verification is received. • or improve for the purpose of sale.). 1. 1 personally plan to provide the major labor and materials for ❑ I,as owner of the property,am exclusively contracting with construction of the proposed property improvement (yes or no) licensed contractors to construct Use project (Sec.7044,Business and 2 {. (have/have not Professions Code. The Contractor's License Law does not apply to ) signed an application for a an owner of property who builds or improves thereon, and who building permit for the proposed work. • contracts for such projects with a contractor(s) licensed pursuant to S I have contracted with the following person(firm)to provide' o r the Contractor's License Law.). the Name proposed construction: ❑ I am exempt under Sec. B.S:P.C. for this Address reason City. Date Owner Phone Contractors License No. 4. 1 plan to provide portions of the work, but 1 have hired the following person to coordinate,supervise,and provide the major work- Name Address City Phone Contractors License No. 5. 1 will provide some of the work but I have contracted(hired) thefollowing perprovide the work indicated: Na Add Name Addrea ss Phone Type of Work Signed: Property owner Social Security number ' Data;