03100126 CITY OF CUPr aTINo �,> kxm--: �. +•d^'•'x . .. `._*`'�' ;
BUILDING DIVISION PERMIT CONTRACTO R�INFORMATION Zz';
BUILDING ADDRESS: JEFFREY SCHULKEN PERMIT NO.03100126
NER'S NAME: 10415 CALVERT DR PERMITLSSUEDATE
ONE: SANITARY NO. CONTROL No.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLOC ELECT PLUMB MECH
0 0 0 0
X00 LICENSED CONTRACTOR'S DECLARATION
1.F 1 hereby affirm that I am rimmed under provisions of Chapter 9(commencing lob Description
;<W with Section 7")of Division 3oflhe B.Onwand Pmfessions Cods, Tal myliacnscis
in full force and effect. ��j
;'y_ License Class Lie.. 2 ADD 280 SQ. FT. I UNIALEM
Dam Contractor
££ ARCHITECTS DECLARATION
C awo
1 understand my plans snap he used az puM1lie¢cords JAN 16 2004
H Licensed Professional
a�-t OWNER-BUILDER DECLARATION BUILDING II��fn II��1�f f�rr'''�'�
y 1 harsh,affirm that 1 am exempt(rum the Contractor's License Law for the IPJl41J81LaILY��tlIl.J1
p O following reason.(Section 9031.5,Business and Profession Code:Anycity or county
e m K which requires a permit to construct,alter,improve.demolish,or repair any structure
°iyprior to its issuance.also mqulms dcapplieam for such permit to rile asigncl statement
• wmatheisrccusedwrciamtnmepmeiaonsnnheCentmciar:Liecnsevw(ehapmry Sq. Ft. Floor Area Valuation
;Fo (commencing with Section 7")of Division 3of the Business and Profeacions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicantfor a permit subjects the applicutto a civil penalty of APN Number Occupancy Type
nut more man five hundred dollars(s5W). P Y YP
❑1,as owner of the property,or my employees with wages as their sure compensation,
will do the work,and the swclum is not intended or offered for sale(Sec.7044,Business
and Professimor Code:The Conmcsor's Liosace taw dors not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employms.provided that such improvements am not intended mortared for sale.IL
however.the building or improvement is sold within one year of completion,the owner- -
builder will have the burden of proving that he did not Wild or improve for purpose of
sola).
0 1.as owner or the prapeny,am exclusively contracting with licensed contractors m
construct the project(Sec.7044.Business and Professions Coded The Contractor's Li
sense Law does not apply to an owner of progeny who builds or improves Ihemon.and
who contracts for such projects with a convactor(s)licensed pursuant to the Conlranor's
cum taw.
I am vempt under 5c�cf^J .Bit PCfonhis mazon
RRKER' M N DECLARATam /D 'U
I hereby altlmt under penalty of perjury ane of the fano ng dedarnions:
I ban and will maintain a Ccr ifica¢of Consent to self-insum for Workers Cumpcn-
atioo,as provided for by Section 37W of the Labor Cod ,for the perfm u nce of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation hourance,as required by Section
37W of the labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy numlter am:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompleted lithe permit is for one hundred dollars($1 00)
or less.)
1 certify Nos in Ne"knona.ee of the work for which this permit is issued.)shall not
employanypmsonin�,,r ppy manner so u m hcc m subjectm the Wm1m'e Compnon
asau
Apps o[ ai not �c
NOTICE PP I NT:Ifasf (making this Ccoificam or Exemption.you should
become subject to the Worker's Compensation provisions of the labor Code,you must
�z forthwith comply with such provisions or this permit shall atdeemedrevoked.
Z O CONSTRUCTION LENDING AGENCY
1 hemM1y affirm that there is a construction lending agency sur the perfurmanee of
2v the work fur which this permit is issued(Sec.3097.Civ.C.)
i7 r- condo's Name
= ,z Lender's Address
j p 1 certify that 1 have read this application and state that do above infmmatiun is
Z U building I agree to comply with all city and county ordinances of and cute laws relating e
DW a moingconstruction,timneand hereby authonmrepPOONO,for inspection dscs. sof Niscity men¢rupon Ota
(We)agree to cure,indemnify and keep hay in an w City of against
against
Z
liabilities,judgments,of the cusuang of this
may in any way accrue against said City
;Jz in consequence of the granting 9f this permit. -
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:S4404aa Date
SOURCE R ULA'{IONS.
o- 'D 3 Re-roofs
Sig f plicanUCu or Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or furore building occupml store or handle havartluus memrial
az BncO by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Ssglioesn 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
Y
Will the applicant tar future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it harardnus air contaminants as defined by the Bay Ama.Air Quality Management all new materials for inspection.
i...ier"
❑Yes 9
1 have read the WaaNnus materials requiaments under Chapter 6.95 of the Cali foo-
nix Health K Safety Cade.Seeuuns 25X)5,25533 surd 25534.1 understand Nn if the building
dues not cmrernly haw a mnana that it is my respunsibilby m noes y the occupanl n(the
,miumm ts Iahmust Wmet poormismanceoraCenlOcateor an . Signature of Applicant Date•
o -O
Ow, r. It. red agent All g
roof coverings to be Class "B" or better
Oat