08090162 CITY OF CUPERTINO 4a; -
BUILDING DIVISION PERMIT "NTxACTQIt INkO�tMATIO. „ ,.
BUILDING ADDRESS: PERMIT N0.
11215 MOUNT CREST PL TBD - TO BE DETERMINED 08090162
NEWS NAME: PERMIT ISSUE DATE
ROBLES F E AND JUANITA C 10/09/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMTTINFO
-BLDG ELECT PLUMB MECH
0 0 0 0
fop LICENSED CONTRACTOR'S DECLARATION Job Description
u I hereby affirm that I am licensed male'prolumes of ChaPmr 9(Commanciay
_i withSmtmn70 )otDivlsion3mfdmBusinessudProfessiomCode,Wmylice—u REPLACE 3 EXISTING BEAM W/ DRY OUTS AT EXPOSED
O N in full roue and effem.
Sp: License Class - Line.N ENDS W/ IDENTICAL SIZE BEAMS
Dam Contractor
eARCHITECTS DECLARATION
? O I estimated my p�dull w used u Public mcmds
a
Is w t; Licensed Prefessia..I
3 OWNER-BUILDER DECLARATION
E I hereby eRm that I am ucmpt from the Cmerumes License Law far the
00 following muton.(Section 701.5,Business and Professions Code:My city W County
$� which metres a pmmit to cansutal alar.improve,demolW,or repair try Con ctum
_Z i prior to its issuance.alr requires the applicant for such permit to Gk a signed summent
that he u licensed pursuant to the provisions of the Conuadur'a License Law(CMpmr 9 Sq.Ft. Floor Area Valuation
mourn ncinywiihSecdon7000)ofDivuion3mfdtcBusin=mdProfessionsCude)or $4450
3 that he u exrmpt thm erefroand the basis for the alleged exemption Any violation of
session 7031.5 by try applicant fora permit subjc=the applicant to a adVll Penalty tot �I�t Number Occupancy Type
am mart than Rion h radmd dollar,(3500). 3 5 62 6 02 6 .-tN
❑1.u towner of dm properly.m my employees with wages u Noir sok compewdon,
will do On work,and One structure Is notiumnded oroRered faraJe(Sec.7014.Business
ano Professionsx:ans CoThe Cantrusors Limine law does nut apply to.n own,,car Required Inspections
property who wilds or improves dmreao.and who does such woak himself or m much his
own empkycea,Provided that such itn'twmenu are amine "offered fmssle E.
howevc,the wilding or improvement is sold within on,year of cmnpletion,the ownor-
builder ,will have On burden of proving that he did am wild or Improve for purpose of
sasal'.).t,u awns N the pmxim
peny,am eaclusawly contracting with licensed centrs On
met the ptojccl(Sec.7044.Business and Professions Cede)The Canvasses V-
«nse Law doss rt apply to an owner of properly who builds or improves thereon.and.
who contracts fm such prejeeu with acon.I.O.)Hamed punuam to the Contractors
Lmeme Law.
❑I am catnaps old,,Soc. ,B B PC fm Nis moron
�a�-wrs.Naw Dam/p-9-•08
WORKERS COMPENSATION D RATION
I hereby Nim under perWty of Perjury,one of the following declarations:
smon,❑(have sedideiforby Session
of Cameo to Code.for as for
for by SeNmn 3]00 at the Labor Cox.fm the Performance of Ne
wale for which this pmmit ts iasi
I have and will mainuu Workers Compnmsdon bas ..u wired by Section
3700 of the Labor Code.for the podurnanee of the work for which this Permit Isuum. '
My Workers Compensation We.artier and Policy number am:
Cartier. Policy NO.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
Thu maim recd trot wcmnplemJ if the Permit is forom hundred dollar($100)
or leu)
I a'tifv out In W pertons.of the work for which Nis Permit is issued.I"I no,
employ any Person in try mann,,an u to become Object to the Woduess'Compensamn .
A 1of Cilif
NOTICEt
NOTICE TO AIPLICAW.If.after Compensation
this provisions
of Exemption,you ushmild
m
become subject y the Workers Compensation previsions of the laver Cade,you muss
.J 0 faMwiN amply with such previsions w Nu permit dull de domed uevakcd.
'Z^' CONSTRUCTION LENDING AGENCY
[+� I herehyaBism wt Nem Is.conOuctlna lending agency,far On rowans anauf
D: ti the work far which this permit is issued(Sec.3097,Civ.C.)
Q Lenders Name
O z Lcnxr,Adxe..
U O 1 certify Nat I have mad this appRwion and sum that the above indormadon is .
V, E comes I agree to comply with all city and county ordinances and sum lawn relating m
0 CS^1 building Construction,and hemby suNarim representatives of this city to enter upon the
[17 above-mentioned pro mly for Inspection purpues
t„ G (We)agree to ave,indemnify and kap homless On City of Cupenuo so=
N Iiabilidcs judgments.cuss and expanses which may us my way seers against said Cy
U Z in con,equcme of the turning of Nu permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:S Date
SOU E ULAnONS.
Siynu o(ApplicavVCen� 019 Re-roofs
�D-9D,
te
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will
tic Smit or future building oavPant store or handle accordions,mamrial
defined by the CupenMo Municipal Cade.Chapter 9.12 and the Health and Safety
.SmOm 25532(.)] All roofs shall be inspected prior to any roofing material being installed.
�Ym UP.
nIf a roof IS installed without firs[obtaining an inspection,I agree t0 remove
Will the a pliant or future wildig 9snoprt use equipment or devim which
emit huctdous air conumimnu u defined by Ute Bay Ama Air Quality Management all new materials for inspection.
Distr cR
❑Yes eo
1 haven mad the IuuNws materials requiremrnu undcrchapas6.95 ofthe Califte- /7
wHWthBentlyhomamvuuss505,25ymm125534.i wWcrmnde aifdmnt ofOn .�O—
docs not currently haws mors Nu itumy ce.r.Ocrutonotifythemmvpant of Jin ^'VMI ! VC�� G.
mom entswhknmuNb m ertoiueraer.enre.marO very. Signature of Applicant Date
Owner or mthovad,gem Dam
All roof coverings to be Class'"or better