04110036 (2) CITY OF CUPERTINOBUILDING DIVISION PERMITCONTRA.CT,OR�INF.O.RMATION
BUILDING ADDRESS: PERMIT NO.
W A FARNHAM CONSTRUCTION 04110036
AM : PERMIT L4TJE DATE
E:
SANITARY ROL N0:
lAng) 378 8522
ARCHITECT/ENGINEER: BUILDING PERMRINFO
BLDG ELECT PLUMB MECH
L_OZ LICENSED CONTRACTOR'S DECLARATION Job De$Cr] LOA
0
til F I thereby affirm that 1 un licensed antler provisions of ChaDe Y(rommencing P
i� with Secq'on901)0) fDivision 3afJell ounkitv-PymfcuiumoCause�q Indy licevcu
iamnrady a f aL j/ tic.« / DT�/j 7 REVISION- -EXTER. WALLS (S . /W. ) _
2 License C(e3
n- Dale Coal ties
A H EC SD LA ATIO NO NEW PERMIT ISSUED/ ORIG. 404060044 _
a 1..&.,and rnf2. uuJ as
a Licensedm(Fationa I -
OWNER-BUILDER DECLARATION
3 1 hereby affirm that 1 Our acmpt from the Cont.moo License Law for the
00 which ng mason.(Section](131.5,Business and use dt ions h.or:Any city at county
$ which requires a Permit m wms the alma improve,demolish. fi mpsig any strucmm -that
in its issuance.pursuant
mqo the sheapplicant for such permit Glcsligandamemem
,,'n NatNancirivedpumtion7 )ofDiviovofoeConuiness ndPrefcsw(CNpmr9 Sq.Ft. Floor Area Valuatio
�I-m (rommennng wish Section r0007 of Divition3nf NC Business and HvfusiOV Cook).1
115
Or
$ Nos the u exemps therefrom and the hasu for the alleged esemption.Any violation of
Section 7031.5 by arty applicant for a permit Subjects the applicant to a civil penalty of APN Number Occupancy Type
nos mom Nan I..hundred delta.($50(0).
01,u Owner of the property.or my employes wish wages u rich sale compensation, 34214084 . QO -
will do the work and Ne structure is at mended oroffercd forsale(Sec.?Obs,Business
orad Proressiov Cade:The Contracmrs Lice=law does rte,apply m an owner or Required Inspections --
property who Wildsorimpmvei Hereon,and whodoessuchwork himself mthenigh his
own employes,provided Nal such improvements art not inended or offered for sale.If.
mineveq Ne building or improvement is sold within one year of completion,the"net-
builder will have the burden of Driving that he did not Wild or improve for purpose of
sae).
0 1,u owner of use prepcny,am exclusively contracting with licensed ronuacmrs in �)
consumer the podca(Sec.9(aa,Business and Professions Cade:)The Contractors Li-
cave Law does not apply to an owner of property who diads or improves Nemon.and
whofor such projects,with a convanor(s)licensed pursuant m the Contractor's
nu LaLo w.u \\\`
❑1 am.temps under Sec. .B&P C for this moon
Owner Dal
WORKER'S COMPENSATION DECLARATION
Ihereby affirm under penalty of perjury one of the following declarations: J
I have and will maintain a Cenifcue tiu
of Consent elf-insum for WorkersCompcn-
tion,u provided for by Section 39W of the labor Cade,for the performance of the -
work for which this permit is issued.
0 I have and will maintain Workers Compensation Insurance,u uquired by Section
3900 of the Labor Code,for the performance of the work for which this permit is issued.
My Workd ¢cnsatio In nee carrier and Policy numNr ate:
Car. r Policy Na.:
CEM OF EKEMPTIOH ORKERS'
COMPENSATION INSUMANCE
(Thu section need not the completed if the permit is forone hundred dolla.(SIW) rare rare.or less.)
I certify that in the performance of the work for which this permit is issued,l shall not .-
employ any pecan in any mannerso u in become subject m NC WorkersCompensation
Laws of California.Data
Appliram
NOTICE TO APPLICANT:IL after making this Cerificae of Exemption.you should
become subject to the Worker's Compensation previsions of on,Labor Cndc,you must
.JO foMwiN comply with such provisions or this permits hall be dotend mvnked.
Z 0
CONSTRUCTION LENDING AGENCY --�-�~
F (hereby affirm that Nem is a construction lending agency for Nc purformancc of
C the walk fur which this permit is issued(Ss.109E Civ.C.)
W QLende,'a Name
6. Lender's Add., //_ /•�
tJ O 1 am y Nat I have mad this application and sure Nat she shore information is
W F commit.l ague tp comply with sit city and county ordinances and we laws elating to
0Ubuilding construction.and hereby auNotirempre¢nerier of this city m enter upon the
r W alcove-mentioned property for inspection purposes.
(Wer)agree to save,indemnify and keep harmless the City of Capenino sgaimr
nF'.t r6'/1 liabilities.judgments,costs and expenses which may in any way same against said City
U in conugvnccofthegraming of Ni ermit. w
^+ APPLICANT UNDEMPLY WITH ALL NON-POINT Issued by: Dat '
/z I /
SOUgfiFjRGGAT10N3 �`— .11
��!!/�/Y t 7 ll// Re-roofs
Signature o A plicamuConuaaor ate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building weupantstom or handle hazardous material
as defined by the Cupenmo Municipal Cods,Chapter 9.12,and the HcaWt and Safety
Catic,S cuon25532(a)? ,..t� All roofs shall be inspected prior to any roofing material being installed.
0Y. 1911.
Will the applicant of future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it he'rardoes air cone minantl as defined by the Bay Area Air Quality Management all new materials for inspection.
isvicl? �D
❑Ys
Z. Ihavemd Ne hams Dusmvcrialsmquimmcnuundcr Chaper6.95ofthc Glifor
nu HcatN&Safctycod,Sections25505.25533and25534.Iun&mrs Nuif Nc Nilding
foci not curt<ntly have a tenant ar t is ponmhilily m nouly Nc ore.panl of Ne
mVu nts maatNmet dor anraCemreaeoraapapcx C SignatureofApplicant Date
Ter Or a omcdd agent
5 �( All roof coverings to be Class "B"or better