01030143 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10340 BUBB RD 01030143
ill OW'NER'SNAME: APPLICATION SUR DATE
41 1 HOME OF CHRIST CHURCH 03/26/2001
'HONE: _ SANITARY NO: CONTROL NO.
[on
RCIII I'ECT/ENGINEER: BUILDING PF.RMI'1'NFO
s u G BLDG ELECT PLUMB MECH
P<'a 7I I=1
Z N= LICENSED CONTRACTOR'S DECLARATION lob Description '
o z_o I herehy acorn Inhht 1 am reeh,w hinder pnh,i,ionn urClhapwre aohnhmnemg P
F,mFwith Section 7l«q)nI'Divi,iun 3 of the Bminasand Pmfe,si...Cale,and my license
mlI force and Cheer. SIGN
GN
o a lacen.e Cors. Ue.'a .
�3 a.y, Date Comachm
ARCIIITLCI'S DECLARATION
t a,j 1 understand my plah,,hall he micro public records
CzaF
C O Limn.uJ&ofcaional
OWNER-exempt?fo DECLARATION
d w I maon.diem thin 1 am,exempt from the lContractor C x License law hu the
2 C billowinghirec.(Sntia.70d L5.Business and Pndcssiom Cudc:Any cilY or emmy
'F Drier mryires a pem�il lin conewch alrnr,improse.Jemulirh,nr mpi it any structure
.d]m
"l to it,i.smnae,also«quires ffirr' licunl lar such pentotolden signed halm,
that he is licensed pursuant to the provisions of the Contractor's license Use(Chapter 9 Sq. Ft. Floor Area Valua[ibn '
(emhntonci as with Section 7000)of M,mon 34 the Basi res,and Prof„ions Cco,)
or that he Is exempt thercfmm amt the basis for the alleged exemption.Any violation $2000
of Section 7031.5 by any applicum for it moria subjects the applicant 1.a cis it penalty
of did more man five hundred dollar.(6500), APN Number Occupancy Type
❑L a,owner(if the Fri or my employee%out wages as their sale cmnpen,ation. 3572001 9. 00
will do the work,and the smaure is not intended or offered for sale(See.7044,
Basun„and Profe„Idn,Code:The anvmamr',U,tal Law does not appq to an - Required Inspections
owner of propetm
y Who hada.or impres thereon,and who does such work hit self
taaglthisowdemployee,.IF...dedtintwInimprovement,areno,amendedm 304 — ROUGH ELECTRICAL
offered for sale.If,however,the building or improvement is sold within one)car of
cnmpledon.mcowoer-bndder will have the burden of proving that he did not build or 501 — FINAL ELECTRICAL_ ENEP.GY
improve for of.ale'. 505 —• FINAL ELECTRICAL
01.as Tal'the propemys ren exclusivity inntruting with licensed rommcmrsta
condom,the Project(see.9044,Bus and Profession,Cadep"The Comracmr', -
License law thaw not apply m an saner of pmpcny who Wild,or Tummies doom.
and wooammeu for such prct
oje ,Mire ,d u dIn a,nmmmor(nl Nova, pun, the
Contactors License law.
❑1 ren exempt ander sec. .R m PC f r thhs mason
Owner nine
WORKER'SCQMPESAT1ONDECLARATION
1 hcimm affirm under penalty of perjury uric nT the Iidluwing declarations:
V7 I have ant will n ainwin u Cmiticam of Consent u)mlbinw,m far WO,ker's
"omperodim, as pr.,idcd far by Section 3701 of the Lather, Code, for the
Perfnhrnumc of the work fur loch this,on lit i....ucd.
01 use unit Mill nminmin Worker',Compensation Insurance,;is required by Section '
3701 of the tabor Core.Ire the pOldoounce of the Mork for which this pemhii is
wed.My Wbder,Competsatinn lnnugae«:,,He,and policy number me: '
Caniee Policy No,:
CERTIFICATION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
flBis sectiun need not he completed if the penial is for One hundred dollars '
(5l ap ar loss.)
I cenify that in the Ivtormmme of the work for which this permit is issued,1 -
,hall not employ anY penin in any manner so a,Us become while,to the Worker,
Co h"mation Low,of Caldor in.Date
Applicant
NOTICE TO APPI.ICANL If,alicr nhuking This Cenhticate of I!xemp,inn,you should
Z becoam subject do the Workers Compensation provisions or the Labor Code,you must
Q O rmhwith comply with such provisions cr this pcnnit shall be denncd h'cvoked.
z
F h CONSTRUCTION LENDING AGENCY 1
I hereby affirm thm there is a consweticon lending agency lin the pafomexam
W of the work for which this permit is Noticed(Sec.3197.Civ.C.)
L IE Lender',Nance .
= z Lander'.Address
V I certify that I have mad this application and Nae that the above imodracfon is
G.h (o correct.I agrre to comply with all city and County ordinances and Nae lows rotating
0 [) to building comlmction,and hereby amortize opm,entatives of this city to enter upon
�, (y the above-nhuntioh ed pmrety for h,poiliurpo,,,
(we)agree m,me,indemnify and kap harmle„the City of Coronado amm,
(A liabilities,judgmeas,cane and expense,which may in any way doer..against said
U z City in consequence of the gaiting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Q /�
SOURCE REGULATIONS. Issued by: Date
Shgnmurc al Aprlmant/C'ARDO r ac Re-roofs
HAZARDOUS Mdi.,doALS DISCLOSUREtoguar
Will rho apto,hmfmmrlwJdCo arvpanu,urcor Handle Healmn Sidery Type Of Roof '
a.de,S,c by h25 Cupaninn Municipal Gde.Chapmr 9.11,and the Hcahh:uul tiafdy
CnJc.S,etion 2553?(u):'
030, ON. All roofs shall be inspected prior to any rooting material being installed.
Is Will the applicant or future milding occupant use equipment or devices which ,If a roof is installed without first obtaining an inspection, 1 ree to remove
end,haorolnus oar cent:uni�n t,an de0ned by the Hay Arta Air Quality Managcmem g p :g
Districrt all new materials for inspection Applicant understands and will comply with
0 Ye, F1 No P
all non-point source regulations.
1 hale mad the lia,Safety
olde. onatcord,5054 mmeons.suer chapter ard3 d the
California mia irl,do N et eminently
Caly lasea accu55,th.3333 and?5534.1.nJemand khat
iftheant oftamsnot curealy haleamoan,,Lhaitis myssuancsiofa eiramify Tho
occupant of the rcyuirenan„which mus be met prior m issuance nl a Ccnilicae of
Occupancy.
Signature of Applicant ' Date
oMmrnrmihonretlagent Date All roof coverings to be Class "B” or better
OFFICE