01070005 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT N0.
18870 TILSON AVE. 01070005
OWNER'S NAME: APPLICATION SUB DATE
JON WILLEY 07/03/2001
PHONE: SANITARY NO. CONTROL NO.
O a0 ZO ARCHITECT/ENGINEER: BUIL G PERMIT INFO
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i CJ J I__J CI
LICENSED CONTRACTOR'S DECLARATION
C 5 y? Job Description
O Z_O 1 hereby affirm hat I am licensed under pod Frons of Chapter 9(commencing
prw
l-be with fall ome..itef Division Jof the Business and YmfessionsCWc,and my license TEMP POWER POLE.
z Y I is in full force anJ effect.
c a Lit Class Lic.a
a'O a'� Nate Contmcmr
3 a fi: ARCHITECrS DECLARATION
u O J 1 undersand my plans shall be used as public records
2mriles..
Q: a Licensed Praha...do.]
°w' e LL OWNER-BUILDER DECLARATION
=' I hereby aRrm mar I an,exempt from he Como...w'a License Law for the
following reason.(Section 9071.5.Business and Professions Code:Any city in county O O
sO which requires n permit m wmstrvn,alter,improve,demolish,or repair any swewre Y
3> Pnn to is res al. q silo. ppti ;I s d per Diu
tmb.ohe is
licantforapermit mnbj<ns rhe License
is cams I,,,(C
,,,(Cl lap;uepntenaerint9yt
, ,•,
Mdt_a.h
On
7ksf)ofDico,ioo 3 Buame,,und prolfid,wo,nmm 3
clubs,be is exemno the m amt the basis(orhe allegedexemption.Any violaton
of Scctany..p
,of not more than rive
hundred dollars Issdm 103 APN�jr l" ., Occupancy Type
-404 PnTT(-LI El ECTRILT,
❑1.as owner of rhe propenY•or my employees with wages as Meir role compcnvtion.
will do the work;andd-the structure Isnot intended or offered for sale(Sec.7044, Required Inspections
'Business and Profdsions Cade:The Contractor's License Law duce nor apply w an q p
weer of pmpeny Who Wilds or impro.Ts hereon•and who docs such work himself
or through his c ply provided Ih t such improvements am not intended or _
DR<<df ' I If ;h my 8 pro i'i;-;.Id h year ld of t -
complt t rb Idc Ilh hch rdc fp gh thedA no,Wild or
imp e p noo.se otl sale.).
as'Wre,aithep "c m<d zi IY cot i 6 th1 xd ; ourstd
con iuct the project(S<.7141 B:nc d Pr ,fes ora Cocap Th C ¢Demi s ,, ,, I License La d not apply I o r f property who W Id p me...
and h ;ars for-such.pmt is with. connections)( d p m.;o the
C° tract Lc L
❑I p;andnandn Get—"' (JB@PCT rhv reason �j ' - t •
(/ Dads
' WORKER'S COMPENSATI ND.CLA ATION
1 hereby affirm under penalty of perjury one of the following declarations: V/
❑ I have and will dommin a Cerificme of Consent m self-imam for Workeri
_ Condominium. as provided for by Section 37W of the Lob; Costa. for be
_ performance of he work for which Ibis permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
_ 7700 of h6 Labor Code:for the Performance of rte wod',for which this permit is
isacd.My Workers C°mPcremion Insorena carrier and Policy number art:
Carder:1 `I Policy No.: 'i .
CERTIFICATION OF EXEMPTION FROM WORKERS',, ••COMPENSATION INSURANCE
(This section Decd not W complied if he permit is for one handled dollars t -�_ _ •
IS 10U1(Thise(
•'''1 cenify,ihai In the.performance or;Ae work for which chis permit is issued,1 ,:
'shall not employ any person in any manner so as;o become subject to the Workers' ,
Compensation Laws of Califomia'Dare
Applicant - . .. I . . . - _
NOTICE TO APPLICANT:IL after making this Certificate el Exemption.you should •t' '• •'
•Z became object m the Worker's Compensation provisions of the Labor Cold,you must
O O I hwith comply with ach pbecomn,or his permit shall he deemed revoked.
Z, CONSTRUCTION LENDING AGENCY
of t
�; 1 mildlymildlyafEno that there is a cohsvuatimr lendingy,agency for me,pl,rf°rmaoce
the work mi
I ' t
r rk'(or which hii pert is issued(Sec.JIN],Civ.C.)
Lender, e_.
�.Q 'Name`- _ _ _ _ _5.
Z Lender'd'Address' I
jr
V � I certify that l have dead this application and arae that he above information is
correct.I agmm to comply with all city and county milm:mces and scare laws relming
O.V 10 Wilding construction.and hereby authorial,representatives ofthis city to enter upon
he rhove-mcnitored p pet f inspection p r x:
lW 1 b o e t0ev Ify and keeph -mles.the Ctyo rCupertino:g'nst
✓i liabilities,j.d,mmm,.Cost, v1 asperse,which rim,in an,way.,me against aid.
U Z Cly l of he training.1 Inpe r ..
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT- Issued by: Date'
SOU E REGULAT10N5 - /Z/ Y
s amdegrApppcuntlennwamr Dole Re-roofs
HAZARDOUSMATERIAas dl,E llhh he Co Drub foomb dingo Ch noacein
handle
Type of Roof - -- — -- - ---
Code,secnun 25572x1? r .. a a the Health and-Safety'-
pp 'r a g p store 2.handl h eaN° '
' r9.l�,an
I.
i`, �. ' .
.,qv°" ''' ' ,' "°'' �' ' '1 ' ' I -� ' . All roofsshall be inspected prior to.any_roofing.material.being..installed............
Will the applicant or future building°ccup t use equipment or devices which If a roof is ini;611ed without first obtaining an'inspectiofi; I agree t0 remove
anti;haaardnas air containment,as defined little Bay Area Air Quality Mana,mem
Districe all new materials for inspection. Applicant understands and.will comply with
° e`,*. all non point source regulations. -
1 hale=it the Itiaallous materials requirements under Chapter 6.95 of the
Califomia Health&Safety Code.Seaiom 25505.25533 and 25534.1 undersand mace -
"dthebullJingdoes not tt:rently haveamnan;.hai;is my m.pnnxibil'ny mnrnify rhe -- -
difirm of the rcquirtmmis which 'k;be met prior to issuance of a Certificme of
(/�/opy Signature of Applicant Date
n mime;:ed agent .r �Y Date All roof coverings to be Class "B" or better
- �-OFFICE