00080061 CITY OF CUPERTINO PERMIT No.
BUILDING DIVISION PERMIT CONTRACTORJ�NrF. ,_ORMAT�ION:;.
r
BUILDING ADDRESSI 0963 WILKINSON �AV J K MASONRY QQ��
SANITARY NO. ICAYIAUBMITfAL DAT
OWNERS NAME. LODIGA RICHARD M AND NANCY L 400 HODGES AVE (i
NIC
ION:: ' ❑
(408) 287-2398
ARCHITEC(ENGINEER .`13ULDING 1'I:RMI'T INFO
M.z
rew�
tars _
>S y= l hereby affirm dui I.m lliicenseddad
CTOR res,,proviisiCo c of Chapter 9(commencing .lob Description
oTION
z L. wins=ctl7000WDivision 3 of me Business tom Prore,eiooacost and my a«mei. CHIMNEY REPRIR
-fes in fun force sad effec,
uu d s z 2Licause Class Lic.0
S LL U Delo Contac-r
ARCHITECTS DECLARATION
$C N I understand my plans shall be used u public reminds
e.e.E:QO o u«med pr°fessdw
OWNER-BUILDER DECLARATION
C Z>• I hereby affirm that 1 an exempt from lie Contractor's License Law for the
f s lad following reason.(Section 7031.5.Business and ROfeuiom Code:Any city m county
.3g whish"ideas;•pdmi"°cauw='•ate*,improve.demrlWt,or a*,any stints Sq. Ft. Floor Area Valuation
former,its i.wence,also restores the applicant for such permit-File a signed statement $2365
that he is licensed pursuant to the provisions of Ne Contractors License Law(Chapter 9
(=°mmencingwithsectirn7=)orDivision 3oftin Bti,i.and—1—iomCme)« APN Number OccupancyType
that he is exempt thetcfmm asst the basis for the alleged exemption.Any violation of YP
S«frn 7031.5 by any applicant for a permit subjects the applicanuo a civil foenaty Of 3_9613030. 00
nal mete Nen Five hundred dollars(S5ME.
❑I.a,rwmrortneaofomr.dmyemptoy«a withw,gesutheirwlecom«m,tion, Required Inspections
will do the work,and the structure is not trimmed or offered for sae(Sec.7BTn,Business
w pore:nom Code:The Contactors License law man nor w,I,to to owner of 101 — FOUNDATION
Insistently who builds orimpro.«Verson,arm who does men wdkhimself athtmgh 312 — CHIMNEY REBAR R STRAPS
his own employees,pmviaea that such improvements ate and intended or offered for
We.If.h°wevey the building or Improvement s suld within one yearof completion,the 514 — FINAL PUBLIC WORKS
wmrhJder win have doe buNen of proving Nat be did ret build ter improve for pd-
pose,dwo.).
❑L as owner of the property,do exclusively contracting with licensed Onommona to
construct the project(Sec.Ida,Business and professns Code:)TTc Contmtor's o-
dds law dust,da apply to m owner of property,who hila,or improv«drrtrn.and
who contracts for such projects with a emitsmum(s)licreaed ponuant-the Coodommrs
ucrosc law. nj
❑Lem exempt uaden Sec. .B@PCfor this rruon Vy
Owner Data 5�
WORKER'S COMPENSATION DECLARATION ///�"
1 hereby affirm under penalty Of perjury cone of din following dech,atiata:
I have and will maintain a Certificate of Consent n self-mite for worker:Coni n-
sation,as provided for by Section 37W of the Labor Code,for the perforrmnee of the
work fa which this permit is issued.
❑1 have,rd will maintain Workers Compensation Lmumnce,as requited by Storrs
37W of the Inbar Cade,for the perf°rmecce,Of the work for which this permit is issued.
My Worker,Compensation Insurance center tad Poixy numbs ane: '
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sessic oneedretbecanpleted ifds,perms is future hundred"Ism(SIM)
Or less.)
I certify that in the performance of the work for which this Summit it is issued.I shall
nor employ any pore°.in any manner an as to liamme,subject to the WorkerCompen-
sation laws of Calif nsm Date
Applicant
NOTICE TO APPLICANT:if.after melting this Certificate of Exemptiam,you should becomes subject to the Worker's C°mpenution provisions of tic Labor Code•you must
farthwdb comply with such provisions to this permit shall be deemed rooked.
CONSTRUCTIGN LENDING AGENCY
I thereby affirm Net Nene is•construction lending agency for the perft munee of
z Ne work for which this permit is issued(Sec.3097,Civ.C)
F. lander,Name
C > leaders AIdtesa
I comfy that 1 have need this eppllcation and stain met the mfomulion is
0. A c°nect.I•gone to ca°ply with all city and county ordinances aid some laws mlaung-
.7 Z building commcdon,and brom,sudwnze orpor,enwiv«°f this city to anter upon the
V above-mentioned property for impectian purposes
(We)allies,to save,indemnify and keep harmless me City of Cupertino apinst
Q L.) liebilmes,jadgments,ca-sad espenses which ony in any way accweagaiOst said City
in consequence of do,granting of this permit.
ti IL APPLICANy1%N lilatil'ANDS AND WILT.COMPLY WITH ALL NON-IY)INT
� SOURCE RLGUI 'II)NS.
U Z
a 7i.-..v ry--N
Signe tcdf Applic.nVCrnlum I Date
HAZARDOUS MATERIALS D CLOSURE
Will the einfasom.,for.Wilding acct nate ut hma2a hazWaus mrmull Re-roofs
as drfimd by the Cupertino Municipal Cade,Chapter 9.12,ail the Heath and Safety Type of Roof
Code.Section 2551]107 YP
❑Yes ❑No
Will the applicant or future building occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
mit insuN...am contaminmu ss defined by the Bay Ar«Air Qmiry Management installed. If a roof is Installed without first obtaining an inspection
strict' I a ree to remove all new materials for inspection. Applicant
❑Yes ONO g
Ihave read the hazardous omtenas mquitcmrn
ts ander Chapter 6.95 of the Cali- Understands and will comply with all non point source regulations.
mania Heath&Safety Code,Sections 25505.25533 and 755 1 on a. thinif do,
buiidin8d ac mlY havicetenanL thu it is my tesponu ny in notify the occupant
of the mifcue nr Occuparcy.
• �+- {ice Signature of Applicant Date
euthonzed agent Dam
All roof coverings to be Class"B"or better
rl
OFFICE