05090060 CITY OF CUPERTINO *d'€ .fT T✓C mar t�d +"%��°�^ " ";-�Nuu "
BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION '4
BUILDING ADDRESS: JUDITH/LANGE/KEVN THOMPSO PERMIT NO.05090060
10881 BARRANCA DR
sR'S NAME: PERMIT ISSUE DATE
JUDITH/LANCE/KEVN THOMPSON 09/27/2005
+E: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB AAECH
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si eip
LICENSED I am Homed
CONTRACTORS DECLARATION of CON
1 ionby affirm that 1 am f he Bu undo add
Pr iona ofCutterCaulk.
9(commencing Job Description
,, with Senior ndeffec Division lof NC Business and Profession Code.and myliecnaeu
'I N in fm nneanaerrerL REVISION—ADDITIONAL. WALLS REMOVED AT
License Class Lic.a
adm D.m Contractor GARARGE—TWO INTERIOR WALLS
'ty ARCHITECTS DECLARATION
3 a I understand my plans shall W dead as public records
J
n.tU
y�7t; Licensed Pmfnaional e'
Oat I am oxempi l DECLARATION
1hereby
naso .(firm that 1 1. cxcmpt Imre Nc Cessions o License law for the
')2O followingmoon. Penia 7M1.5,Business and ve de sena Cadc:Any city or county
which requires a permit ro consWCL eller,improve,demolish,or repair any swoon n 17
in prior In its issuance,also requires the applicant for such permit m fle a signed nammem
-TG Nat he is licensed nindaidto the prvismasoftoComrecmr'sLicenuLow(Chque,9 Sq.Ft.Floor Area Valuatio 214
ei (commencing with Section]000)o(Divokm 3 of the Business and Professions Code)or
-
that he is exempt tMrefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subiccu the applicant to a civil fatally of APN Number SQccupancy Type
not man door fire hundred dollars($500). 32601010 . 0 0
❑1,as owner of the property,or my employees with wages u their sole compensation,
will do the work and the structure is not intended or offered for sale(Ser.7044,Business
and Professiona code:The Coom ore,License law does ml apply he an owner of Required Inspections
property who builds or improvee thereon,and who doenauch work himself or through his
own employees,pm.idcd Nat such improvements are notimended oraffered for sale.If.
however,the building or improvement is sold within one year of completion.the owncr-
builder will have Ne human or proving that he did not Wild or improve for purpose or
sale.). _
?1.as owner of de,property,am exclusively contracting with licensed contractors to
moswct the project(Sec.7144.Business and Professions Code:)The Connector's Li-
toe law docs not apply to an owner of property who Wilds or improves Ihemon,and
who concocts for such pmlem wish a conmctons)licensed pursuant in the Connector's
License law.
❑lam ere oder Sec. .B&P C farOilmatin
Data
WORKER'S COMPE14SATION DECLARATION
I heuby affirm under penalty of perjury ane or dtc following declarations:
tare and will maintain a Ci nificam of Consent to self-iname for Workers Compcn-
n,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 haat and will maintain Worker's Compensation I....as re,mo d by Section
3700 of the labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am: ,
Cartier. Policy No.:
CERnFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed rule permit is forone hundmd dollars(SIM)
or less.)
I ccnifv Nat in the performance or the work far which this permit is issued.I shall riot
employanypermninanyonnet arm Wcoma sub'e to tW Workeri Compensation
Laws of Calif. — —
Applicam .n
NOTICE 70 APP IKANT.If.after making this Cortiricare 6r Esomption.you should
become subject to the Worker a Compenu ion provisions of the labor Cock.you miss
:7z forthwith comply with such provisions or this permit shall W deemed rovaked.
Z.0 CONSTRUCTION LENDING AGENCY
f I hereby affirm that Nem is a convection lending agency lot dm performance of
Got' 7 the work fur which this fermis u issued(Sec.3091,Civ,C.)
Ll QLeaders Name
0, Lender's Address
az
CJ 0 1 oenify that I have rod Nis application and sum that the above information is
U. cormeL 1 agree to comply with all city and county ordinances and state laws relating m
U Wilding convection,and hereby wNdout mproentRUnt of Nis city to enter upon the
above-acro m cd property for intpecsian purposes.
(We)agree to save,indemnify and keep harmless the City of Caper inti against
liabilidea judgmen¢costs and espeves which may in any way accme against said City
in`)z
APPLICANT eUNDEof the RSTANDS Aof tND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE EGULATION .
✓� ��' Re-roofs
gra mofApplic6k
HAZA DOUSMATERIALS DISCLOSURE Dam Type of Roof
Will the applicant or russet building..,.at$tom or handle hazardous material
defined by the Cupenlno Municipal Code.Chapter 9.12,and the Health and Safety
c,Seenon 25532(.)? ...���/// All roofs shall be inspected prior to any roofing material being installed.
Oyer Dp Nu
Will sW applicant or future building occupant use equipment or deices whim If a roof is installed without firs[obtaining an inspection,I agree to remove
hazardous air comitants as defined by the Bay Area Air Quality Management all new materials for inspection.
via?
❑Yo 1Nu
1ban read the e.Sc,nusmamrulsn33rud n5underdenuar6.95 oflic Glding
fin-
rias not &Safety Cod e,Secdonv anti myrmv125514.1 undersande Oifthebuilding
does not currently hose a mnan4 Nat itis my responsibility m notify Nc occupant of Ne
whim be p
ma. dorwiamceofeceNlic.sc cup nr. Signature of Applicant Date
Ou er or aumorivad ascot Dam All roof coverings to be Class"B" or better