04100061 CITY OF CUPERTINO
Huao1NG DIVISION PERMIT : CONTRACTOR7.NFOtMA -
BUILDING ADDRESS: PERMIT NO'04100061
0 410 0 0 61
21 RS A - PERMIT MUE DATE
OWNER'S NAME:
C14RIS JERBIC
NE: SANITARY N CONTROL NO.
ARCHI'IECf/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
=oo LICENSED CONTRACTOR'S DECLARATION Job Description
m❑ 1 botchy affirm that 1 am located under previsions of Chapter 9(commencing P _
2 with Scction7")uf Division3of,be Busineasand Professions Codc.andmylicenscis
't2y ADD 304 SQ. FT. FOR KIT. /DINING/FAMILY
m full force and effect,
,—z Date Class Conti
�_tj Dam Contractor.
ARCHITECTS DECLARATION
9, 1 understand my plans shell M1c used as public records
�yU
G„f,
Licensed Professional -
so 3 OWNER-BUILDER exempt b DECLARATION
+� I hereby affirm Nat 1 1. exempt item the Contractor's License Law for the
opo followingmoon.(Section 7031.5.Business and vefdemolli Corte:Any city or county
K$ which its is a permit re construct,th almc improve,h Permit t or repair any uncture
yZipoor to its isswnee.also requiter the applicant for such Permit file asignee summent - -
< that he is licensed pursuant dpursuanotheprovisionsormeCommetur'sLicenseLaw(Chapter9 Sq.Ft. Floor Area Valuation.
X (commencing with Section 7")of Division 3 of the Business and Professions Coal M, '
i .. Nes he is exempt shehfrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of 3M erOO ---Occupancy Type
not more than five hundred dollars(S500).
❑I,as owner of the property.or my employees wish wages as their sole mmpenstlon,
will do the work,and Netwnuse isnot intended or offered for aide(Sec.]064,Business Required Ins ection -
and Professions Cade:The Conlm oor's Licnse Law does not apply to an owner of q P �--a
own enywho
es.pralds orimprovssuchim mand who sumdoes
not chwnedoroflfotthmugh his
employees,lding or
impetration'
tiimpmvld wit sum not intendedoroffesed fors war-
however.the Ne building or improvement is hath within Otte year of completion,thepose of ))
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
NSI,as owner of the property,am exclusively contracting with licensed contractors to v
oLoact the project(Sec.7044.Business and Profession Code:)The Contracmrs Li.
cone Law does not apply to an Owner of property who Wilds or impravrs do mon.and
who comment for such projects with a contmemr(s)licensed pursuant to dm contractees
License Law.
1 stn exempt oder Sec. B k P C for this mason
tuner
vie
/ I WORIRIERSCOMPENSATIONDECLA loN
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Conant to elf-insure for WorketaCumpon-
ariden,as provided for by Section 3700 of Ne labor Code,for the performance of the
work for which this Permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as mquimd by Seeuon
3700 of the Labor Code.for the Performance of the work for which this permit is issued.
My Worker's Compensation Insumnm carrier and Policy number am:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not he completed tithe Permit is formic hundred dollars(SI00)
nr less.) -
I certify thus in the performance of the work for which this Permit is issued.I shall not yr-
employ any person in any mannerist as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation previsions of the Lehr Code,you must
O forthwith comply with such Ph viiinn or this permit shall he deemed my food.
Z CONSTRUCTION LENDING AGENCY
I hereby afftrm that these iso construction lcadingagency for Ne Performance of
fY .� the work fur which this permit is issued(Sec 3099,Civ.C.)
W Lender's Name
lY Lender's Address
IJ I modify that I have road Nis application and state that the above information is —\
commit,I agree to comply wish all city and county ordinances and state laws heating to
pU building construction,and hereby optimum onpromnmtives of this city m enter upon the
r W above-mentioned pmperty for inspection purposes.
(We)agree to save,indemnify and keep hafmlon the City of Cupertino against
F' raj) liabilities,judgments,costs and expenses which may in any way accmc against said City
U Z in consequence or the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
v'r�
SOURCE REGULATIONS, ;;✓/ - 6& T_
`
y' Re-roofs
Sig at 'of pmant/Comractor D
HAZARDOUS MATERIALS DISCLOSURE,, Type of Roof
Will the applicant or future building Occupant store or handle I moirdous mmeriai
as defined by the Cupenom Municipal Code.Chapter 9.12,and the Health and Safety
Adlikodo.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes gNa
`VBI the applicant or mtum building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hic,am us air w umi lams as collard by the Bay Arca Air Quality Management all new materials for inspection.
IStrieO
El Yes ori.
I have mad the ba cedous materials tequimmems under Chapter 6.95 of the Califor-
him Health&Safety Coale,Sccuun25505.25533 and 25534.1 undorsmnd that if he Wilding
does not currently have a tinam,that it is my ma miscbinty to nouly the occupant of the
requirements which most he met print to issunme ofa Cerifcam of Occupancy. - Signature of Applicant Date
' /W 4/ L , �����/d u All roof coverings to be Class "B"or better
Owner 'r. a m Dam i