22453 PERMIT NO. ISSU€D BV DATE BUILDING PERMIT APPLICATION. OWNEF-RI ut DER DECLARATION LICENSED rONTRAGTOR DECLARATION COUNTY_OF SANTA CLARA BUILDING INSPECTION OFFICE t hereby affirm under penalty of perjury that 1 am exempt from the I hereby affirm under penalty of perjury that I am licensed under
70
Lt7 ',✓�[� (f/ (1 -W,HEDDING ST.SAN JOSE,C495110 - Contractors License Law for the following reason(Sec.7031.5, provisions of Chapter 9(commencing with Section 7000)of Division 3 of
Business and Professions Code:Any city or county which requires a the Business and Professions Code,and my license Is In full force and
JOB ADDRESS GEOLOGY permit to construct,alter,Improve,demolish,or repair any structure, effect.
0^�� -7 �e �• prior to Its Issuance,also requires the applicant for such permit to file
--1 �7 ac4 t
statement that he or she Is licensed pursuant to provisions License Class Lic.No.
CITY f ZIP CLEARED FOR ISSUANCE BY DATE of the Contractors License Law(Chapter 9(commencing with Section
CV • U` C � ❑ INSPECTION REQUIRED PRIOR TO FINAL INSPECTION. or she
01 Division xempt 3 of erthe Business and Professions Code)a that he Contractor Date
NEARE'^STn C OSS STREET or she Is exempt therefrom and the basis for the for
eexemption.
Any violation of Section 7031.5 by any applicant for a permit subjects rnuc7aur_.nnN LENDING AGENCY
�\1 a PLANNING the applicant to a civil penalty of not more that five hundred dollars
OWNryER ` PH E SET BACK(FEET):FRONT SIDE REAR ,($500)): I hereby affirm under penalty of perjury that there Is a construction
�� �r �5F..1 qP I,as owner of the property,or my employees with wages as their lending agency for the performance of the work for which this permit Is
O ll^IO W �a ZONE: sale compensation,will do the work,and the structure Is not Issued(Sec.3097,Civ.C.)
MAILING ADDRESS Intended or offered for sale(Sec.7044,Business and Professions
S
DATE Code:The Contractor License Law does not apply to an owner of Lender's Name:ZIP CLEARED FOR ISSUANCE BY property who builds or Improves thereon,and who does such
CITU work himself or herself or through his or her own employees, Lender's Address:
ARCHITECT/ENGINE 13 INSPECTION REQUIRED PRIOR TO FINAL INSPECTION. provided that such Improvements are not Intended or offered for
,A sale.If,however,the building or are
is sold within one I certify that I have read this application and state that the above
MAILING ADDRESS LAND DEVELOPMENT ENGINEERING&SURVEYING year of completion,the owner-builder will have the burden of information Is correct.I agree to comply with all city and county
proving that he or she did not build or Improve for the purpose ordinances and state laws relating to building construction,and hereby
CITY ZIP of sale.) authorize'.
uthorize representatives f thl county to enter upon the above-
DATE ❑ 1,as owner of the property,am exclusively contracting with mention d property for n ecl pu ses.
CLASSlLICENSE NO. PHONE CLEARED FOR ISSUANCE BY
licensed contractors to construct the project(Sec.7044, I( a
❑ ROAD IMPROVEMENTS Business and Professions Code:The Contractors License Law Da —
CONTRACTORI does not apply to an owner of property who builds or Improves Slenature of Aooticam
W n e r, ❑ DWY APPR. thereon,and who contracts for such projects with a contraclor(s) HAZARDOUS MATERIALS
MAILING ADDRESS ❑ OTHERS licensed pursuant to the Contractors License Law.) (FOR NON-RESIDENTIAL ONLY)
❑ I am exempt under See Indlcate If the intended occupancy will us hazardous materials.Initialing
CITY ZIP ❑ INSPECTION REQUIRED PRIOR TO FINAL INSPECTION. Yes acknowledges that H&S Code Sections 25505,25533,and 25534 as
well as filing directions were made available to you.
CLASSILICENSE NO, PHONE ROADS&AIRPORTS
Owner � Dat ❑ Yes
LOTITRACTAPN
r —/�—_L''YCLEARED FOR ISSUANCE BY: DATE L3 No
�:5-7
PLAN CHECK NO. PLAN CHECKER CODE YEAR ❑ FIDIMPROVEMENTS lORKERS GOA PENSATION DEDE L�?RATON CASHIER'S VALIDATIONS
1 hereby affirm under penalty of perjury one of the following
DWY APPR' declarations:
TYPE OF IMPROVEMENT. REROOF ❑
❑ INSPECTION REQUIRED PRIOR TO FINAL INSPECTION. ❑ 1 have and will maintain a certificate of consent to self-Insure for
BUILD ADDITION LTERATIO REPAIR MOVE CONVERT DEMOLISH workers'compensation,as provided for by Section 3700 of the
Labor C
AREA STORIES DWELLING UNITS ENVIRONMENTAL HEALTH permit is Issued.
the performance of the work for which this
❑ 1 have and will maintain workers'compensation Insurance,as ul.i!c.�•!vi ..� 11 u%+i�'1
PERMIT NO. OCCUPANCY TYPE OF CONSTRUCTION for the performance
J. �-
CLEARED f-0R ISSUANCE BY DATE required by Section 3700 of the Labor Code, pe .c
of the work for which this permit Is Issued.My workers'
JOB DES IPTION _ ryry ��' [IHAZARDOUS MATERIALS compensation Insurance carrier and policy number are:
C
❑ WATER SYSTEM PERMITM Carrier
Policy Number
❑ SEPTIC SYSTEM PERMIT a (This section need not by completed If the permit Is for one
hundred dollars($100)or less)
❑ INSPECTION REQUIRED PRIOR TO FINAL INSPECTION.
I certify that In the performance of the work for whish this permit
FIRE MARSHAL is Issued,I shall not employ any person In any manner so as to
become subject to the workers'compensation laws of California, n r �ry u �^
and agree that If I should become subject to the workers' ,,n,r lnr.:nq, n-
VVI x.J7 Vr T�f..Ll 11 VV1tY V'Y tui
COUNTY FILE NO. CLEARED FOR ISSUANCE BY DATE compensation provisions of Section 3700 of the Labor Code,I ';U 110 iiia +T-05• u-
shall fort th comply It ho provisions.
500 SCALE MAP NO. ❑ INSPECTION REQUIRED PRIOR TO FINAL INSPECTION.
Date
SPECIAL INSTRUCTIONS Appllwm V
VALUATION
FEES WARNING:FAILURE TO SECURE WORKERS'COMPENSATION
COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO
PLANNING S.M.LP. CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARS($100,000),IN ADDITION TO THE COST OF
SEPTIC
FIRE MARSHAL COMPENSATION,DAMAGES AS PROVIDED FOR THE SECTION 3705
PLAN CHECK PERMIT OFTHE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
aw w+
OTHER
Inspection Data Sheet - 7/19/2002
Permit 2002-22453-00 B Issued 6/24/2002
Location 10495 BYRNE AV, CUPERTINO, CA Zone 2 Fees
Cross Street Building 85.00
Owner TORRES, DAVID J
Contractor
Owner Phone
Job Desc Tear off existing and install 20 year comp
❑Geology ❑Land Develop ❑Planning ❑Roads/Airports ❑Environ Health ❑Fire Marshal ❑
Called Date Insp Phone Code 1 2 3 4 5
Request,7/18,102 8:20:23 AM 7/191102 4085958379 ST11 0 0 0 _ 0
Code Comments Date Insp Disposition
RR01 TEAR OFF 7/5/02 DMC Approved
ST10 ROOF NAILING/SHEATHING 7/8/02 DMC Approved
F101 PROJECT COMPLETED Corr 7/17/02 DAH Disapprove
F101 PROJECT COMPLETED Per corr 7/19/02 GMS Approved
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