01080088 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:'
BUILDING ADDRESS: PERMIT NO.
10165 CAROL LEE DR WM H FRY CONSTRUCTION COTIPANY01080088
YV�SNT3"AFTER SERVICE 10351 SAN FERNANDO AVE 081/ 17 f 2001
PHONE: (408) 996-8173 SANITARY NO. CONTROL NO.
mm eco le ARCHITECTIENGINEEIF - BUILDING PERMIT IN
w— BLDG ELECT WM MECH
z 5 y Z LICENSED CONfRACfOR'S DECLARATION Job Description
O z_ 1 hereby affirm that l am licensed under provisions of Chapter 9(commencing
E..yFcu with Section 7000)of Division 3 of the Business and Professions Code,and my license NEW WATER SERVICE.
Y I all force a fee,
.w
6 Ce nsa Clas _ Lic.# S2079 f
w3 tam —0 Comracmr
B ARCHITECT'S DECLARATION
} 1 uncle onpl tl Ipy-plpns shippe u.ed as public
ma id:
u p C Licensed Promsess�/imulll /fes-1�
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from Iho Contractor's License law Bn,he $300
F G fallowing mason.(Section 7031,5,Business and Professions Code:Any city or county
S O which requires a permit to construct.Eller,improve,demolish,or repair any structure
,as 3 z .—pr t t issuance,c<al eq thapplicantf hpermit t 11 signed statement
a. but he licensed pinsma,be pro'.io .mine Coronations License Law(Chapter9 Q.-�QL^t�r/,�p}'�l Orrpaa.a Valuation
fc mmt cng with Sec, 40001 of Divi.' 3 fthe B s, e5 ad Pfyfesxrons Code) -3 1*2J'W•/® Vl "'k P $• ,"' '
or hat he is exempt therefrom and the basis far whe alleged exemption.Any vi ilmimi "
-ofSection 7031.5 by any vpplicam for a permit subjects,he applicant,o a civil Penalty
of amorme,han five handraildoExry SNXF. 202APNID�fl¢JRFLOOR PL MBING '' Occupancy Type
01,as owner of the properly,or my employees with wages as theirsole compensation, 301 ROUGH PLUMBING _
—will do
ext;; ' Pro md ssions Codas d.Th i5 not intended orofferedLa doefar snot(Saapply an ii'" 502 - FINAL PLVA5kWGns�6Tdta0Y
'Business and Professions Code:The Contractor's License Law docs now apply m an
owner of progeny Who builds of improves Inereon,and who does such wank himself
or 507
' nth Hl employees.pm'dhimprovements
p , 'w intended
5 0 7 - FINAL PLUMBING
or d po1 m building on p 1 Id within Zincyear of
6omplation,the
web Id ll have the landerarproving that h dd not bundor
- - -"- ----"
improve car p Hw. f sale.).
[JI as owner oftem
_ / L f en tam exclusively iter 0hbu,I Id md contractors
r o lh,ercot
I 4Business
Contractor's LilL
Com0 1 ISf f lulth projects with dh commt1Ks)licensed Panm,on the
L
❑ emexempt undeStl&P .. _. - .. _... .. .. .".:.
1.
._.
Oemcr... ;i .. :.DaleWORKER'S COMPENSATION DECLARATION
I%-
1 h mby eft-m I p Iry of pv) y n•of,the follawmg dKlaretmns:
❑ 1 h end v111 anctimm."a Lertificam of Consent to self Isom for Worker's
Compensation, as provided far by Section 37W of ,he labor Code, for ,he
pefformvna of the work for which this permit is issued.,
_ ❑1 have and will ma maid Worker's Compensation in. as acquired by Section
_ 3700 of the Labor Code,for the,performance of the work for which this permit is
d My Worker's Compe mon insu At
Policy number arc
Cm
.CERTIFICATION OF EXEMPTION FROM,WORKERS',
COMPENSATION INSURANCE"""" ' �•
e
(Th v sialim need not be completed f the Permit is for one hundred dollars
131001 onus)
..::i Iacuity ill.,in the performance ;he wok1for";all inpe t s s J I
'sM1 11 not employ any person in any mann r to as to hanxime simieFut to,he Workers L 1 s
Cminfambnom
.. ..P.aws f Calf " Date
APPIcam
.. .. .... ..
Q
,NOTICE TOAPPLICANT If fm makingf Exemption,- eshould
Obe e.ub3en to the
WoCompensation provisions of e Labor C dyou mus,
fdnw¢h comply with
s h pro, o his p l shall b
-
decand revoked.
EO 'LCONSTRUCTION LENDING AGENCY
5. 1 h by B th 1 th ,m t d gag y f th pertan once
ofM kr rdh eh sh pe t '. ed[S<3097 Crv.C)
U.0
1 I fy d l I ha rc d th ppl t d t t Ih uhe ho mf rmmton is
gT+=Fy c'o t 1 g t ply th 11 c ty a d IY rdln w enJ t m le relating
!;f,) ns hmld ng eons,rodmn,and herehy autharm rcpresemanvts of th'svtym toc'upon
>;Cz7 dhe above-mm,imned property for inspecwion purptses.,
H.a (W g eio , d- n'fyn Jk phartnl< 'the Cty fC gem
gvmdsl said V1 liab I, s) dgments com v d pease hmh m y n any � e
V z ,Ory h consvy encc of ehe 6 ,ng of sh p t r/ �/
r SAP ICl UYD ST1\DS qND WILL COMPLY W'11'HALL\OY PONT UY
Issued by: Date
asd fnedb ahe'C HAZARDOUS MATERIALS DISCLOSURE aw Re
COOfs
Pp D _ Allroofs shall be inspected nor to.an roofing.7 pp bu lding accap t m t n dl n al Type of Roof. -
,g
color ofA IlchntlCommu
wdyI,i Ic t fm « ad P P Y g ..^
y pen M p I Code.Ch pl 9.12 d lh Health nd t '
Cod Section
e t o 2553 [n)
� m,n m Ir ec ton l agree toreinstalled.
Y i N buildingnotation .eequipment a ea which g gree[o remove •
e Will the en d 1 0 Buy Arcn A Q l,y M"ag P 'g pp material bel Will comply with
D I I all newns rstands and
ov „ ,ate " all n materials
ewithout
t A ta]cant understands __ _ - -_ _ .
applicant rft
wnwm , d f
f have mad'th heard s r 1s requirements under Chapter'6.95 of the
QCs mHealth&Safety Code,Sections 25505,25533 and 255,41 undersand that
"t Pontor does mol carman,haswhich
on l that a lhv re uira o I is to locate of
c
nt pf the requirements -hicti mum bem,prior to Is f a Certificute'of
mprt� ....Signature of Applicant .. ..... -.. . .. _- ...._ Date ... .. . .. _ . _.
Owner mhorieJ ag ntDam
All roof coverings to be Class B"or,better
- OFFICE