03030120 (2) CITY OFCUPERTINO thKi
BUILDING DIVISION PERMIT i ON T. -0.9 INS' MAT,I, QN?„
BUDAINOADDRE•SS: CHEROKEE CONTRACTING CO. PERMIT NO.
OWNER'S NAME: 1220 COLEMAN AVE �� n
NE: (408) 727-9850 SANITARY 12 4,12RIMIL NO.
ARCHITECTIENOTNEER: - BUIMINO PERMIT INFO
BLDG ELECT PLUMB MECH
Grp LICENSED CONTRACTOR'S DECLARATION
1 Mreby affirm that I em licensed under provldons of Chapter 9(commencing Job Description
i with Section 7")of Division 3 of the Bmines end Pmfcssiou Code.end my ties=is
^< 'a m
follfoand if
'z
"c""a"
lJc.fr_J�i11na✓ REPLACE SEWER E'lIIIALE®
o Contrmtor�
understanda sARCNIW Use DECLARATION MAR 2��3
1 understand my plehelI M toed u public mnrda2 4
D�
yo Licensed Poor cnlook[ -
OWNER-BUILDER DECLARATION
+� I hereby.offinoSect that 11. exempt from Bic Conlrns Co Any
Law for the BUILDING
`o o which on reason. eormi t 7113 L0.Business and ,r1m ns Cndc:Any tiny s county
$ which royulres n pmmh re quires b L altea Impmm,h permit
or mash any stroctum
'prior hot
its....4also
uantto the Bieapplicant
sof formcthe Contractor's
U. Law statement
p that menden with
pursuant tothe of DivinesnfoftheB sines iliauelAw lChapter9 S({. FI.Floor Area $4V1I17allon
n�$ tham isexemiBiSection70W)Ba Division for wftheBed exem don,Any
or VUU
Thu Section
Is 31,5 b nrcrefmm and the burs for Ne subjects
she e¢mpnon Any violation of gyp
not mo than by any used d.ntforspermiuubjecu Ne applkanlmscivil Penalty of P y'lYP
once mace than Ewhundred amlun(ss00). 31���Ni��bFf00 Oceu ane e '
1,u Owner of the property,or my employees with wages as their role compensation, .
will do the work.and themvcmm boom Intended«offered(orwe(Sec.IDN,Business C IY'Id�3' actiony V�/
and Professions Code:The Contractor's Lt..law don 106 — SEWER IF
not apply be an owner of 9 ,
propeny who builds rimproves thereon,and who does mchworkhimselfor through his 202 - -UNDERFLOOR PLUMBING r'
.. own employees.provided that such Improvements arc not ntended oroRered for sale.If, 301 - ROUGH PLUMBING
however,the building or lmpmwment is sold within one year ofcompledon,the owner- _
builder will hive the burden of proving that he did not Wild or Improve for purpose of SO7 — FINAL PLUMBING
sale.).
❑I,as owner of the propeny,am exclusively contracting with licensed comor m x 10
convect the project(Sec.7001.Business ad Professions Cade:)The Contractor's W-
mile raw does not pply to an owner or propeny who Wilds or impmws thrown.and,
who contnen for such pmjects with a conusemr(O Bernard pursuant in tie Contractors
Licence law.
❑Iamr.emptunder .Sm. ,BAPCfwlhismamn
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of Perjury one of the following dedoratlon3:
have and will maintain a CenlEca a of Consent to self-Iusum for Workers Compere.
ion,u provided for by Section 370D of the Labor Code.(or the perfmmanc,of the
work for which this permit is Issued.
C94%ive and will maintain Workers Compensation Iruunnm.u required by Seddon
7700 of the labor Code,for the perfmmanee of the work fm which Bits permit Is Wood, .
My Werke Co Mmationinm nmcnrierand Polirynumbcra'm1: ' ..
Cartier. 1�Policy No.: L.VN2 ill
CERTIFI AMM '%EMPIONFROMWORKERS'
COMPENSATION INSURANCE _
(This action need not becompleted Base permit is foram hundreddollan(SIM)
nr less.)
1 certify that in the performance of the work for which mhh permit is Issued,I shall not _ -
employ any person in any manneran u to become subject to the WorkeW ODropensnlon
Laws of California,Dom
Applicant
NOTICE TO APPLICANT:If,after making this Cenifino of Exemption,you should
become subject to the Woher's Compensation provisions or the Labor Code,you must
.Jz forthwith comply with such provisinm or this pemdt shall W decmd revoked. -
„zmO CONSTRUCTION LENDING AGENCY -
[-. I hereby aiTnm that Nem is a construction lending agenry,for the Performance of -
a> the work for which this permit n Word(Sec.3097,Civ.C.)
W Q lender's Name
z Lcndcr's Addms - -
V 0 I certify that 1 hove read this application and sum that the above Information is
W F comet,l eine to comply with all city and county Ordinances and state two misting to
p V building convection,and hereby aumhorbe representatives of this city to color upon the
W shove-mcnlloned propeny for inspection Purposes.
(We)agree m save,indemnify and keep hamlets the City or Cupenino against
il] IIabilllies,judgmenu,costs and expenses which may in anyway sant against tato City
V 7 In muetimm. f,h.rimming of this Permit.
�7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SIZE E NS. .
LL V1 : <� Re-roofs
SignalumofApifficarrWommetor Dau
HAZARDOUS MXfERIALS DISCLOSURE Type of Roof
Will lhcipplicantur future Ilding occument slow or handle hadadous material
u donned by the Cupenion M cipal Code.Chapter 9.13,and the Health and Safety
Codr,$conn 35533(&)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ON.
Will the Applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hxvardous air comment...is as defined by the Bay Area Air Quality Management all new materials for inspection.
uvict7
❑Yea fn/N.Nu
I have red the huadousmire
terials requirements under Chapter 6.95 of de Califor.
nu Huua,Safetyeade,Senimsuw5,35333a 73534.IundersuM=irft Wilding
don not currently haw a mount,Biu it is my mpouibilimy m notify Bic Occupant ar the
req ' menu which most W mel Prior to issumed ors Cemrtifeste or Ocmpanry. Signature of Applicant Date
All roof coverings to be Class"B"or better
Owner or mthonzd agent Gate
i