08060086 CITY OF CUPERT,INO
BUILDING DIVISION PERMIT CONTRACTQRINFORNIATION�`K
BUIL INCA DRESS: PERMrf NO.
�.05g4 N BLANEY AVE CUSTOM BUILDING & DESIGN 08060086
W NER'S NAME: PERMIT ISSUE DATE
JON CROCKETT 2980 E CAPITOL EXPWY STE 50 06/27/2008
PHONE: A n-) SANITARY NO. CONTROL N0.
(408) 482-0376
ARCHRECf/ENGaNEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRACTOR'S DECLARATION Job Description
OM�e
C T thereby aDlon Ther I am licensed under provisions of Chapter 9(commencing P
with 5ectian]OfN3)ofDivision 3rk(the Businw coli Professions Code,ad mylkersseu REVISION TO HIP ROOF TO GABLE ROOF OVER BATHRM
sm full forte and effect.
>Lqgz Uc.a.Claa Lr.a ADDTN ORIG #08020017 NO NEW PERMIT.
Data Contractor
pp7W ARCHITECTS DECLARATION
Y I unlicensed my plans shall be it as public rocmda
ayU
C t; Licensed Professional
5 OWNER-BUILDER DECLARATION
<s I herthy affirm the1 am exempt from the Contractors License Law for to
p O following lesson.(Section 1031.5.Boatman and Prefessiom Code:Any city of counry,
K which requires a permit to c:mstsuct.slur,m prow,demolish,or repair any aueuu
LZ prim in in issuance.aLW Iequbas the applicant for such permit to rile a signed Line,ret
EC< Nat he is liccned puruam irk the provisions of the CiM.0 's Lici nm law(Chap err 9 Sq:Ft. Floor Area Valuation
Xl a (commands&with Section 70M)of Division 3 of the Business and professions Cadc)or $O
y that he is eaempt therefrom and the bats for the alleged exemption Any violation of
Section 7031.5 by any applicant far a permit subjects the applicant to a civil penalty of e,pN Number Occupancy
not mom than 0w hundred dollars(5500L 316 3 010 8 .td?N Pane Y Type
1,as owner or the property,in my employees with wages a their sale compensation,
will do the work and the loonch m u not intended.offered foraak,(Sec.]Oast.Busitm
and Professions Code:The Contrisms'.License,Law does ret apply to w rkwhes of Required Inspections
property who buildmimpovestumonand who d.ssucM1workhivoselfm Woogh his
ower employers.provided dulsuch impoowmaus art mot intended ret@ret fursale X,
however.the Wilding or improvement is sold within one year of completion.the owner.
Wilder will have the burden of proving that he did ant Wild in improve fm propose of
ale.).
ry]A.0 owraes of the Prolerty am achnivcly contracting with licensed contracron to
construct the projm(Sec.70x4.Business and Profcasions Crede:)The Contractors U. .
centt Law does amt apply to an owner of property who Wilds or improve Ihemn.and
who connate far such projects with a contraem(s)licensed pursuant in the Contractors
Lkem a law.
Q larnexcmptunde See ,Bk PCf.the mason
mer Date
WORKER'S COMPENSATION DECLARATION
1 hereby atom under penalty of perjury One mf the following declarations:
❑l have and will for by:eCeni3ate atConum Code.
for for Workmen Compere-
work:,aproh thi(pe mi Seaton 3]00 mf the Labor Code.for lite performance of the
work for which this permit is Lssued.
1 have and will maintain Workers Compensation Insurance,at required by Section
37W of the Tabor Code,for the performance of the work for which this permit is issued. '
My Workers Compensation lnsunna artier and Policy number art:
Grier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissecton heed not ccompkted ifthe permit is fmrkse hundred dollars;(SIM)
Or lass)
I cceufv that in the perromahee of the work for which this Permit is issued.I shell not .. -
employ any parson i y mum ss be become subIl to the Wrkrkeri compasation
lawn of Calif
Appliant
NOTICE To A CANT:If.after making this Certificate of Exemption,you should
became subject to Nc WorkCs Compensation provi iou of the lab.Code,you mute
.,O forthwith comply with such provisims m this Permit that be deemm
ed ated.
'EE'y CONST ucnoN LENDING AGENCY
F+ T herehy affirm that dere u a coeuwcdnn lrndinyagenry for the perfine.Of
CL the work for which the Permit Is Issued(Sec.3097,Civ.C.)
D7�Q Landers Name
=z Lenders Address
f,J Q 1 cenify that I have rad this application and cute flat the aurae information is
(T. coerces 1 agree to comply with all city and county onlinan w and sum haws relating to
.p Wilding construction,and hereby suthoriae mprearntNves alibis city to case,upon to
r 4 alcove-meno0ned property for inspection purpmes
(We)agree to ave,indemnify and keep henalm the City of Cupertino against
(~ Ihabilitic judgmcros.costs and expenses which may in coy way sane agaimt=it City /
V z ADPL CANTeUN ERSTANDS AaND moCLL 1PLY WITH ALL NON-POINT Issued by: Date
SOURIIO�NS.
�.c Re-roofs
Sognatum a
HAZARDOUS
AZAUS MATERIALS DISCLOSURE f u� Type of Roof
Will the applicants m future building occupant gore or handle haardoa material
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Sado:
❑Yes �t o 25532(x)? All roofs shall be inspected prior to any roofing'material being installed.
Will the applicant or future building omspant use equipment or devicca which If a roof is installed without first obtaining an inspection,I agree to remove
croft haraNna air cenumimmu as defined by the Bay Area Air Quality Maoagcment all new materials for inspection.
Dismal?
DYes Di
I have mad the heardona mgcrisismquiremrnts underChapter6.95ofthe Califor-
niaHesh"Safey Code.ScsOmu 25505,M533 uu12553.1 udemvad NnJlhe Wilding
doe ret cora ty naw.tenons Wt it u to my responsibility modify ththec occupant of
mgmimme : nmttgeemetpirkrtnLata,ro:oracadrnatetrompamry. Signature of Applicant Date
Owner orauthorbcdagent `— Date All roof coverings to be Class'W'or better