08070131 CITY OF CUPERTINO gs x w+a6v %z taw �*'`. •y '' e�'
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BUILDING DIVISION PERMIT `4CON>TRACTOR INF'ORMATIQN
BUIL I GA S: PERMIT NO.
.RS68�0.ESFARALLONE DR JON R CRASE CONSTRUCTION 08070131
HER'S NAME: ftqc PERMIT ISSUE DATE
164 GILMPN AVE 08/01/2008
PHONE: SANITARY NO. CONTROL NO.
(408) 370-1485
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
30; LICENSED CONTRACTOR'S DECLARATION O O O O
F I Wmby a(Brm ma 1 am 11¢nmd under previsions of chapter 9(commencing Job Description
Sj withSectior70M)afDivision3ordteEmir.andProrcasimucode.andmyliceveis ADD SNGL FAMDWLNG ADD PRCH, FYR,BLCNY&FAM
< ur full fare aM effect.
i LiceveClass Lic.R RM(365SQ) &RMDL ADJCNT TO ADDTN
Dam Contractor
o 1- ARCHITECTS DECLARATION
I understand my plans shall W used as public mcerds
u s
Ztept' Licensed Prommional
OWNER-BUILDER DECLARATION
1 hereby aRrre that 1 am exempt from the Contractors Leena Law far the
O 0 following moon.(Section 7031.5,Businees and Pm Icssinns Cade:Any city w county
$i which.,or.a permit to construct.alter,impmw,demolish,tor mini,any slmemm
Zi priorm its omaroe.also mquims the applicant for such permit m file a signal comment
mm<
that neulicensed purmamtotopmvisiouofthoContainer's U..Law(Clumor9 Sq.Ft.Floor Area Valuation
(comencnem,wit Section 7000)of Division 3 of the Business and Prefaasinns Code)or $200000
y R S tat he is exempt tWmfrem and the baso for to alleged exemption Any violation of
Section 7031.5 by airy applicant for a permit subjects use applicant in a civil penalty or
romm tn five hoodud dollars(SX111i 36939037 Number Occupancy Type
(]1,u owner of tic ptopctty,a mY moployen wit urges u dmirale campewdon.
win do the work,and Inc structurerorottmnded wowd ferulepply D1d,Bassi,of
and enywhions Cade The cnntmcmrc arc".o oes anis ret appy m a owner of Required Inspections
own enywhonuildsorimprama thimpomenwno ammo ch work arofferor tiuuugh hu
awn em.m ebuipresided tat inch impmsemew oR not intended arortaed for owner.
Wilder dm Wildingorden of pmcnttrait whinor year orcorromfor,meowrcr-
W ildm win haw the When of pmHng that W did roe Wild m impose fm purpose of '
am�.
;1,as owner of to property.am exclusively contracting wit liaeneed contradon on
construct to pajca(Sec.7004.Business and Professions Cade:)The Contractors U. .
cove law dors not apply an in owner of property who Wilds or imponm Lemon,and
who carriers for such project wit a contractor(s)licensed poser,on the Commerce,
License Law.
❑lamuemp
I Wmb1'chem under pensby of perjury one of tite following declara0ans:
❑1 have and WI mainuin a Catifieate o(Cantent an self-insert for WedxrsCrimper.
ation,as provided for by Sedan 3700 or the labor Code,rte the performance of the
work for which this permit is Wood.
❑I have and win maintain Workers Compensation insurance,u required by Section
3700.f to VherCode,for to performance oft ,work for which this permit is issued. '
My Workers Compensation four race artier and%lity number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMMON FROM WORKERS
COMPENSATION INSURANCE
(Thu seeden and not W computed iftbe Permit is two=hundred denm(SIM) _
or mss.)
1 cettih mot in me ptrformaeo of the work for which tis permit is issued.1 shall not
emple,any perwn in
dcemed mw4d.
z O CONSTRUCTION LENDING AGENCY
r
F Ihemwh aRrmdw mem is.contm3W.lending agency for the performarao of
rL> dtework for which tiffs pertnitu stet(So..309 civ.C)
�W A Lenders Name
= z Lenders Addm.•
U C) 1 ceniry ma I have read we application and mare tbv the thew,infom m n is
U. cortecL I agme m comply wit all city and county eNlnances and sum laws minting m
0 building construction,and hereby interim mpmcnutisea of this city on now upon me
a Wve-movaentioned property for inspection purp
W (We)agree to ase,indemnify ad kap interim the City of Cuper ino against
(n liabilities,judgments,cosu andespensu which may in any way acme against said City \-
t)z Aconsequence NDER TANoling of AND WILL
Issued by: Date
'-' APPLICANT UNDERSTANDS AND WILL CpMPLY WITH ALL NON-POINT
SO
gnaure of Appli ontractor f Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum Wilding occupantaore orhandlc haurdou mamnsi
u de0ocd by the Cupertino Municipal Code,Chapter 9,11..the Halm ad Safety
Ir.Section,M532(.)? All roofs shall be inspected nor to an roofing material bei"
❑Ya pNo P P � Y g g installed.
Will the. licit o,future building occupant If a roof is installed without first obtainingan inspection,I agree to remove
emit pp g pant ase Area
Air Qu or twins which P
Districtnu air conuminmu u defirod by to Bay Ama Air Quality Management all new materials for inspection.
❑Ya
1 haw mal the haalloumamrialsm9vimmcno under Chapmr6.95 of me Caliror.
ria Halm&SarctyCodc,Scc6.B505.25533 sm125534.1 understood hatifthc Wilding
does ret currently lase a mna,thea u my mspernsi lily m ratify Ne amupant aI the
m!.omm� hicb mats W met ormiau t' crurs:amer Signature of Applicant Date
ice— st
Ow ,"umpired agent D,m All roof coverings to be Class';W'or better
A