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"I=n , wE[ APPLICATION FOR BLINDING PERMIT pm1IKAD0.or(DrIL1AYp n nwLEm to nsuwrc[a c[naKAn rn occurwwcl
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e DEPT.OF PUBLIC WORKS SANTA CLARA COUNTY CONE aMa[I oF.4IY1NT4 MWw. ?� 1`
BUILDING INSPECTION DIVISION U1
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THIS APPLICATION IS A VALID PERMIT WHEN-PROPERLY FlUiD•OUT. SIGNED. AND MACHINE VALIDATED IN 'THE SPACF P[OVIDEp I
PERMISSION I5 THEREFORE GRANTED TO DO THE WORK INDI;EATEDT'IN ACCORDANCE WITH ALL F P�PLIC14BBLLf ORDINANCES, LAWS AND +
REGULATIONS. Cq P�.F1 r `> I •��. '
r'r J.�.�. 1� uG l: C�V..�� 1.1� / �. .
PERMIT IS SUBJECT TO ALL APPLICABLE SECTIONS OF SANTA CLARA COUNTY.ORDINANCE CODE.
M THIS PERMIT SHALL EXPIRE BY LIMITATION AND BECOME NULL AND VOID IF WORK IS NOT COMMENCED WITHIN 60 DAYS.
f'7 "REFUND:WHERE NO PORTION OF THE WORK OR CONSTRUCTION COVERED BY THIS PERMIT HAS BEEN COMMENCED BEFORE THE EX-
PIRATION DATE HEREOF.REQUESTS FOR REFUNDS MUST BE MADE IN WR171NG 70 THE DIRECTOR OF THE BUILDING INSPECTION DIVISION
ON OR BEFORE SEVENTY-FIVE(75)DAYS FROM THE DATE OF ISSUANCE OF THIS PERMIT.'
N GRADE LINES AS SHOWN ON DRAWING ACCOMPANYING THIS APPLICATION ARE ASSUMED TO BE CORRECT. IF ACTUAL GRADE LINES
ARE NOT THE SAME AS SHOWN, REVISED DRAWINGS SHOWING CORRECT GRADE LINES. CUTS AND FILLS. TOGETHER WITH COMPLETE
H DETAILS OF RETAINING WALLS AND WALL FOOTINGS REQUIRED.MUST BE RESUBMITTED TO THIS DIVISION FOR APPROVAL.
INSPECTOR MUST BE GIVEN 24 HOURS NOTICE FOR EACH INSPECTION.
IN CONFORMITY WITH THE PROVISIONS%OF SECTION 7031.5 OF THE BUSINESS AND PROFESSIONS CODE AND SECTION 3800 OF THE
p a 'A `LABOR:CODE OF THE STATE OF CALIFORNIA.APPLICANT SHALL FILE WITH THE BUILDING INSPECTOR THE CERTIFICATES DESIGNATED IN
`
1 H a 0 O `•► ('I)AND(2)BELOW AND/OR SHALL INDICATE ITEM(3),(4),(5)OR(6)WHICHEVER IS APPLICABLE:.
' ' \ '(1) CERTIFICATE OF CONSENT OF SELF-INSURED ISSUED BY THE DIRECTOR OF INDUSTRIAL RELATIONS.
f (2) CERTIFICATE(OR EXACT DUPLICATE COPY)OF WORKMEN'S COMPENSA71ON INSURANCE ISSUED BY AN ADMITTED INSURER.
m (3) ; THE COST OF THE WORK TO BE PERFORMED IS$100 OR LESS.
QT _(4) 1 CER71F.Y THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN
N ANY MANNER SO AS TO BECOME•SUBJECT TO THE WORKMEN'S(COMPENSATION LAWS OF CALIFORNIA. 1
m _ _ (5)_ 1 CERTIFY THAT THE APPLICANT JS'LICENSED UNDER'-THE PROVISIONS OF CHAPTER 9 (COMMENCING AT SECTION 7000)OF
0 OIVI510 ,OF THE BUSINESS A� R FESSIONS CODE AND SAID APPLICANT'S CALIFORNIA STATE CONTRACTOR'S LICENSE NO.
v o2Z r d 1— CLASS C`° IS_IN FULL FORCE AND-EFFECT.
1h (6) APPLICANT IS EXEMPT FROM(5)ABOVE UNDER THE APPLICABLE PROVISIONS OF SEC71ON 7040 THROUGH SECTION 7053 OF
J THE CONTRACTOR'S LICENSE LAW. (STATE BASIS FOR EXEMPTION.)
U A
CC IAPPLI /
Z SIGNATURES
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(J) APPLICANT'S
LL ADDRESS ZIP CODE
• SIGNAIURE
Z DECIMATION OF CONSIRUCFION LENDER
0 �• PURSUANT TO SECTION 1193 OF THE CODE OF CIVIL PROCEDURES.AN APPLICANT IS REOUI9ED 10 1
(_1 INDICATE THE FOLLOL9ING.
1 1
1)NAME OF CONSTRUCTION TENDER BRANCH DESIGNATIor+
0 ADDRESS
D 21P CODE
L.L 3) THERE IS NO CONSIRUCnONCL LENDER.
APPLICANT'S SIGNATURE DAZE
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