01040101 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: '
131111-DING A DURESS: PERMIT NO
1,0519 GASCOIGNE DR ' L711 Q14 101
OWNER'S NAME:, APPLICATION SUB DATE
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OFONE' SANITARY NO. CONTROUNO.
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ARCHITE DE-NGINEER: - BUIL ING PERMIT'INFO
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ZO yFFm .LICENSRDCONTRAC'r012'S DECLARATION Job Description
hcrehy aftlrm Thal I am licensed under pookinel of Charlie, collar a arcing _ P
coil ectle,t,"7 all nl DivivinnJ Af the Business bill Profc,,xin Code,bndnry license
a s 1�n 1.11 lasp dne�rrer,�7 6 d4
as 4—!��I cnnlrach" INSTALL ELECTRICAL FOR HOT. TUB..
ARCHITECT'S DECLARATION
C I Ord...r nd any plans shill be used as p.hire records ,
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Olao.•nsed Pndessicnal '
OWNER-BUILDER DECLARATION
I� '1 hereby affim,thus 1 am exempt from the Contractor's License Law far the
fodewing reason (Section 90.I1 .Hossiness and Prores,ans Code:Any city or county
f A C which requires a Pconit to enilloo,alter,improve,demolish,or error,any structure
3 pare t t ,aleo re'ritel the Pplie tlal salbasDin fifintid,ned,laterreat
then Is ,,licerescdp.,r it a.file p ,,ofm Ccandrand,Twa c La (Cn pter9 S FL Floor Area Valuation
(w ab it Sec( ]INTO) fD' l fth B :ins.and profession,Code) y'
or that he is exempt therefann and the basis for the allegdJ o5emp roe.Any violation _ _
of Section 9031.5 by any applicant fora roma schjccfs We applicbm,n a civil penally
ar not more than five hundred dollars S,100). APN Number Occupancy pe '
°I f the IT pony y etaidayon,withagsns their Ic cor,pereloon,
will do h k and the....... is net intended o,offered f (sec.9044, 37528
Bn, d r f a,lt :Cdr!TI Cont t L :e I, e t apply loan squired Inspections
.won,of properly Who halide or improves thereon,and who does such work himself - -or Ihrongh his own eanployecs,provided that such improvements are not intended or
offered for sale If.however,the building or imprn.emew is sold within one yeer of 304 — ROUGH ELECTRICAL
,mplefmq sur ow„cr-hu'Jeer will have the burden.(provlag Inst he die not build or
irnpru.ero,puwa.ruraale), 501 — FINAL ELECTRICAL ENERGY ' -
❑1,as owaerunneproPerry,an,exclu,sivelyco„tmving with licensed-cmaraers r, 505 - F.INAL ELECTRICAL
continued the project(See.9044,Rosiness nl d Professhma Code)'the Contmtlor's
License Law does flat npplyto do owner of property of builds ear improves thereon,
and who conbaaie for such projects with a commctogs)licensed pursed,no the '
- El Irat ra ci g,l nee Low. „
❑lamucmpt under Sec. ,R&PCfodthia reason
Owner Ila,, 1
WORKEN'S COMPENSA'T'ION DECLARATION
I herchy affirm under penalty of perjury one of the following declarations: _
J 1 have and will tmlnlain a Certificate of Cnnsenl In self-itsnm for Worker's
-aniNi stior, a, provided for by Section 311111 cf the Lew, Code, to, the _
performance(if the work to,which this pemdl is issued.
❑I have and will nwinWin Worker's Compenswinn Insurance,m required by Section
37 of the Labor Code,for the pvoliamnnl,of the work for which this pennh is
a,1.My Werkrrs Compensation Insmmrw carrier and Policy numher ora
Tic, •t+cwSXtar_PolicyNa.: H41410-39-57 ,
CER'I'It iLATION OF EXEMPTION FROM WORKERS'
COMP17NSATION INSURANCE
(This section elect not he completed if the permit is for one hundred dollars
(SIM)or less.) '
I venify that in the performlmee of the work ref which this runup is i,seed.I
shell nA,employ any perste,in any m:umer od as m 1aomc object m the Wod;en' -
CAmpresmion Laws of California,Date —
Applicant
NOT ICE TO APPLICAN'11If.lannnaking this Ccnificam of Fxempt,or,year should
become suhjecno the Workers Compcnsatltn provision,of Ne Labor Codem
,you ust
0 O Innhwi hh comply with such provisions or this permit shall la,licensed revoked. "
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CONSTRUCTIONhere is
AGENCY _
a 1 Innelbyfor alBnn Thal There is s issued(S c. lending agony fur the perfemmncr
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Lender's
work(,which this pem,it Is issued(Sec.3099,Civ.C]
1 z Lender's Name
.� Lender's Address
0 I certify Inas I have area this applhcan and slam than the have mmm,ntina is
ty correct,I agree In comply suite VII dry and wanly Architraves and state laws relating
V to building amsenction,and herchy rectoriu roprewnen e,orthis cityln enter upon
W the ableveorsentioned prnpeny for inspection pugarses.
Q,t (We)tincetovast,Indemnify vad keep harodi the City of Cupenino against —
rI liabilities,juigmants,costs and expeades which may in any way acme agahnst slid
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Cityno
cANTUNIDERSTANDS AND WILL COMPLY
g
ILL COMPLY WITH ALL NON-POINT
so cP H TIONS. Issued by: Date -
f_
erg a Applies n/Gomrrimnr Date Re-roof
HAZARDOUS MATERIALS DISCLOSURE
wiu the npprra,a or far,.bniming nceupanl dos, handle hural a ana,r ial Type of Roof -
vs Defined M1y the Cupenino Municipal Cade,Chapter 9.12,vad the Health nnA Safety
Code,Section 15532(.)^
El Yes °N" a All roofs shall be inspected prior to any rooting material being installed.
Wit I a pheom Ar rawre naueine Ace,apmu ate rrl,dp,nem m devme.wnmb
P If a roof is installed without first obtaining an inspection, I agree to remove
nJt haeuNnuc nit comamiamnts m delinedby the Ilny Aren Nr Quality Monugemem
i.Irree all new materials for inspection. Applicant understands and will comply with
❑Yes. °No all non-point source regulations.
I have read We b forolaus maheriels oNgluenmats under Chapter 6.95 order, ,
California Health ea Sef ty Code,Sections 25505,25533 and 25534.I undemmno that
Vic
ildingoen Dat nnemtly Lave a natant,ilia,iris my reapotsibiliry to notify the
ftherequiann,emswhich anew,be ,to prior no issurnce of a Cedificnle of
r;ay _ Signature of-Applicant - Date
Af 6( All roof coverin s to be Class `B" or better
autbndved agcnl Dane g
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