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TV APPLICATION IS A VALID PERMIT WHEN PROPERLY FILLED OUT. SIGNED. AND MACHINE VAFIDATEP IN TIiE)SPACE PROVIDED'.+LSV"' W^ L'
PERMISSION IS THEREFORE GRANTED 70 DO THE WORK INDICATED IN ACCORDANCE WITH ALL APPLICABLE ORDINANCES, LAWS AND
REGULATIONS.
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PERMI7 IS SUBJECT 10 ALL APPLICABLE SECTIONS OF SANTA CLARA COUNTY ORDINANCE CODE.
THIS PERMIT SHALL EXPIRE BY LIMIfATJON-AND-BECOME_NULL AND VOID IF WORK IS NOT COMMENCED WITHIN 60 DAYS.
rnS. "REFUND:WHERE NO PORTION OFTAE WORKORCONSTRUCTION COVERED BY THIS PERMIT HAS BEEN COMMENCED BEFORE THE EX-
P_ i �• (PIRATION DATE HEREOF,REQUESTS FOR REFUNDS MUST BE MADE IN WRITING TO THE DIRECTOR OF THE BUILDING INSPECTION DIVISION
T1 t �'Irl ON,O�BEFORE SEVENTY-FIVE(75)DAYS FROM THE DATE OF-ISSUANCE OF THIS PERMIT."
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0 j GRADE•CINES AS SHOWN ON DRAWING ACCOMPANYING THIS APPLICATION ARE ASSUMED TO BE CORRECT. IF ACTUAL GRADE LINES
y: ARE NOT THE SAME AS SHOWN, REVISED DRAWINGS SHOWING CORRECT GRADE LINES, CUTS AND FILLS, TOGETHER WITH COMPLETE
1 DETAILS OF RETAINING WALLS AND WALL FOOTINGS REQUIRED.MUST BE RESUBMITTED TO THIS DIVISION FOR APPROVAL.
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INSPECTOR MUST BE GIVEN 24 HOORS•NOTJCF FOR EACH INSPECTION.
IN CONFORMITY WITH THE PROVISIONS OF SECTION 7031.5 OF THE BUSINESS AND PROFESSIONS CODE AND SECTION 3800 OF THE
I a `� LABOR CODE OF THE STATE OF CALIFORNIA,APPLICANT SHALL FILE WITH THE BUILDING INSPECTOR THE CERTIFICATES DESIGNATED IN I
(1)AND(2)BELOW AND/OR SHALL INDICATE ITEM(3),(4),(5)OR(6)WHICHEVER 15 APPUCABLE.
' (1) CERTIFICATE OF CONSENT OF SELF-INSURED ISSUED BY THE,DIRECTOR OF INDUSTRIAL RELATIONS.
To (2) CERTIFICATEI(OR EXACT DUPLICATE COPY)OF WORKMEN'S COMPENSATION INSURANCE ISSUED BY AN ADMITTED INSURER.
CD (3) THE COST OF THE WORK TO BE PERFORMED IS $F00 OR LESS.
Ck (4) I CERTIFY THAT IN THE PERFORMANCE OF THEW RK FOR WHICH THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY ANY PERSON IN
CLI ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKMEN'S COMPENSATION LAWS OF CALIFORNIA.
(5) 1 CERTIFY THAT THE APPLICANT IS LICENSED UNDER THE PROVISIONS OF CHAPTER 9 (COMMENCING AT SECTION 7000)OF
DI I N OF THEjjLJSINESS A D PR FESSIONS CODE AND SAID APPLICANT'S CALIFORNIA STATE CONTRACTORS LICENSE NO.
a .-4 .
J CLASS �_15 IN FULL FORCE AND EFFECT.
CE (6) APPLICANT IS EXEMPT FROM(5)'ABOVE UNDER THE APPLICABLE PROVISIONS OF SECTION 7040 THROUGH SECTION 7053 OF
1 THE CONTRACTOR'S LICENSE LAW.(STATE BASIS FOR EXEMPTION.)
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Z I DECLARATION OF CONSTRUCTION(ENDER
O ( PURSUANT 10 SECTION 1193 OF IHE CODE OF C191L PROCEDURES,AN APPLICANT IS REQUIRED 70
u I INDICATE THE FOLLOWING.
O -, \ •M, 1)NAME OF CONSI RUCTION LENDER BRANCH DESIGNATION
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a ; APPLICANT'S SIGNATURE v DATE
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