07100220�z
LC
yC
�C
�C
jF
C.
�P
J2
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
6-CONTRACTORINFORMATION •.
BUIfDN FSS:
-
PERMIT NO.
MENHART LN
J.A. CHAVEZ CONSTRUCTION
07100220
OWNER'
SANITARY NO. CONTROL NO.
(408) 247-3006
ARCHfTECT/FNGINEFR:
BUILDING PERMIT INFO
BLDG Is err PLUMB MECH
LICENSED CONTRACrOR'S DECLARATION
ol
lb Description
p
iml 1 am licensed under p am of Chapter 9 (commeming
1 hereby affirm a ti
with Secaon 7=) of Division y ofdm Business an Parrasam Cot.ladenyis
REVISION —TRUSS CALCS;ORIG #07060039-NO NEW
N fool force and cried.
Licenm Claw _' Lic.p "�"
PERMIT.
Dam
ARCHITECTS OECIARAa as
TS DECL
I undcaunJ my plans shall W nsed an Public r¢ortlr
- .. .
Cleansed Pmressional
OWNER -BUILDER DECLARATION
1 hereby aInm that I am canmpl from the Comaerar't Limn¢ Lew for the
following reason, (Secu m 710I.S. Business and Professons Cade: Any city in cmumy
which mquirm a Permit w construct alma "Par.. demolish, or repair any auuctme
Prior a its nowarice. also requires IW applicant for such Permit in fit s signed slammanl
or the Contractors U¢uaa Law
Sq. FL Floor Area
Valuation
Nat he is licensed pwsuanl to the provisions (Chap=9
$0
Section withSection Mai of Division 5 of IW Business and Profmimu Cot) or
that he is csempt Nerefam and the ham, Tor the alleged ascription.Any vlolWon of
Number
3 7 5 15 076 6
Occu anc T e
p y yp
Section 70515 by airy applicant for a permit subjects the apPlionl w a cv0 penalty of
not man: man fiw hundred dollars (SM.
: Yl tl�
❑ 1. u owner of tins Propmy, m my wployem wiN edged u IWk ma mfepemtim,
Required Inspections
will dathework, andthe an Busiries
awcofedtole(Sly
an COMboatintendedne law dons to
and ons Ceder TW CantMors apply a rt awns
and who or is
property who builds or impro.v Hereon. and who daesauch work himmlfm through her
erty wh
own employees provided moRerm. red saln, B.
emmu are omimo
ore
gorimpmwmantis midicdid cam)carofhaps.foraremvner-
epr wincom is s
hswever,areow
W ildv wW have IW Wrarn M paring Has W seta nm build m Wprow The pmpax of
th
mle.1.
❑ I. as aww of the prapeny. am exclusively conuminL with licensed mnh¢Ims a
comtmct the pmjm (Sec. 70". Buslnea and Profession Code:) The Commences U.
ccmn Law tm not apply w son awra of Property who Wilds or impm n dratmrt and.
who contracts for such projects with a mnuanor(q limmma pursmn, to the Conuanays
License Law.
❑ I ens escmpt under Sec . B & P C for dus reams
Owner Door -
WORKER'S COMPENSATION DECLARATION
I hereby aflrm untr pemlly of perjury om of the following dedantians:
hose and w11 mainuin • Cerdficau of [mums wself-imure fmwi nufcComper-
Lion, u pmvidcd for by Section 3700 of the labor Code, for, the Performance or the
oh for which can permit is issued.
1 have and will maintain Worker's Compensation Iasurana. as, agtdsed by Section
3700 of the Labor Cot, fm the Kit---- m Ne work fed which this Permit is I"-'
'
My Workers Compensation Insurance carrier and Policy number ere:
Carrier. Policy No.:
CERTIFICATE OF EXEM PEON FROM WORKERS
_
COMPENSATION INSURANCE
mus scWrn herd not be eampimcd if one coraft Is for cam her dmildoBam (SIOM
or Imo)
I certify Ihcs in Ne petromua of we work fed hicb this fib toed. I shill cam
employ any Person in any mmmr an 1a-gE ab)rgY 'Ap Compen .
Laws of cafifiarmse8me
Appli acts
NOTICE TO AP G m If. almr meting Nis CcrtiOom caption, you should
lineman subjml Ne Wm1wr:s Compensation pa scions a Lahor Cock, you mat
' forNwithco y with non povisiom m Nu prone a d==ard revokrA
j
CONS. ON LENDING AGENCY
is a c lendingsp:my fed arc nerfomsna or
lmad
1 hurrwhslfim Nm N=rt is=nd!
IS .30
' ✓m wurk fed which Nis Permit is issued (Sec. y091, Cl, G)
Lender's Name
Lcntr's Adam..
j I certify that I have tail this application and sum Nu too information infoation is
' emnem i agrce to comply with all city and county ordinances sand soon laws muting to
building conmucuon, and hereby authorise reprmrsuuvu of this city in e mrupnn the
ahove-mentioned pmpcny for impecdoa Purposes.
I
(We) agree to saw, indemnify and Imep harmless the City W Cup mum against
j liabilities. judgmenm,cosu and capemns which may In any way amue against Wd City
Aconwyucnce or Ne granting of Nis It
' PPLIC UNDERSTAND WILL COMPLY WITH ALL NON -POINT
Am
Issued by: Date /�
SOU NS.
Re -roofs
L
Sign 6fA VCanamur Date
HAZARDOUS MATERIALS DISOX)SURE "
Type of Roof
,it rho applicant or Tereus Wilding occepom rare or bundle installations mataiW
wed by the Cupertino MunicoiPa Cot. Chapter 9.1 L snd the Health and Safety
. anion ussy(.)7
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or ramrt Wilding occupant am wainmm in Micas which
edit hi Mons air Micia nano er rhea by the Bay Are. Air (mahly Manac=m=nt
all new materials for inspection.
ohmic,?
❑Yer
I have read N=hvadous ma, Is quirearnuundes Oupms6.95oflho Califon
NmifNcelarLng
nia Heal f'T
xcamuhal,
he ymmo7353a.1uridvnand
dma cum he a Irnent Nu it' my aspomibility a notify Ned mcupant of Ne
req wan m Wmet issuameof. afo.Yapamy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
owner, anNadnad scot Dam