04120036 CITY OF CUPERTINO. aa*s�aw ,��.;+"; ,J, - - --
BUILDING DIVISION PERMIT CONTRACTOR�INFORMATION S
- -BUILDING ADDRESS: ROBIN SUNG PERMTTND04120036
21593 CASTLETON ST
OWNER'S NAME: PERMnISSUEDATE
CHRIS JERBIC 5946 BOLLINGER RD 12 /06/2004
NE:
SANITARY NO. CONTROL NO.
(408) 257-1827
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
+=+op LICENSED CONTRACTOR'S DECLARATION I Job Description
'
C 1 hereby affirm that I am limned under provisions of Chapter 9(commencing p -
Zty with Section 7")af Division 3ofde Business and Professions Code.and my license is
��„ imfull fame and effect. REVISION--IN HOUSE USE ONLY -
5`t2? Liermew ClassLie,N
Zoo Dare Contractor NO NEW PERMIT ISSUED/--ORIG. $ 04100061 --
''' ARCHITECTS DECLARATION
I understand on,plans shall W used As public me uhs
JyU
3 k- Licensed Pmfcssianal
i Q 5 OWNER-BUILDER DECLARATION
I hcmhy aRrm that 1 I. exempt from the Contractors License Law for the
p 0 follwhich
tures a Permit(Sccd
AIn a Busin r,imp Professions denim ta.of m Any city smashcounty
K m which require a pemit re cowua,alma improve.h Permit t ar repair any swcture
Fly pdorwiucensed pursuant
requites the
ovisio antsof for suchoulth S cCaee,Law
xummcm
he (commeni«nudpurstion7 h)of
u3ofbe OC usinssanttnulaw( hapter sCode) 9 Sq.Ft. Floor Area VahIM$t 8191
ec~$ (cat he is(commencing Section nand th but$on l of the egad Business and Proon.An foes Code)or
that he is exempt thc¢Irom and the breis for the alleged cxemplion.Any violation of
Section 7031.5 by arq applicant for a permit sobjecu the applicant in a civil penalty of APN Number ane Occu Type
not more man five hundred dollars(M). 35618059 . 00 Occupancy
yp
❑I,es owner of the propcny,wmY emplayeea wire wage as Meir sok campenadon, -
will doOno work.mid rbeuoreure is im(nomdcd or offered forsalc(Sce.low.Busitvss Required Inspections
and Professions Cade:The Convector's Licensedes Law does not apply m an owner of .. _ q - - -
property who Wilds or improves thereon,and whodoessuchwork himselfortluaugh his
own employees.provided met=it improomanu Are nm intended or offered for wk.It, — -
however,me building or improvement is sold within one year of completion.me owner.
Wilder will hese tine burden of proving that he did not build or improve for purpose of `VA
sale.).
❑1.u owner of the property,am saclusively convening with licensed contractors to ` r�
construct the pinjen(Sec.7054,Business and Professions Code:)The Conuacbr's U. . `
cense law does not apply to an owner of property who Wilds or improv memon,and
who contracts for such projects with a convaooKs)li«reed pursuant to the Camnctars -
Licenu Law.
❑I / Pel un« «. a& so
Co
PC for this man --
r,j --
.IVIJ RKER'S COMPENSATION DECLARraiTION
V 1 hereby affirm under penalty of perjury one of the following declantimrs: -
haveandwillmaindinaCertifieate of Consent to self-insure for Workers Compen- -
.on,As provided for by Section 3700 of Ne Labor Codc,for the pertormance of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,a required by Section -
3700oftheLuWrCode.fay the performance of the work for which this permit is issued.. .-.--- --------- -- - --
My Workcts ComPemaimm Insurms,carrier and Policy number are:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This it.need not be completed true Permit is form.hundred dollars(SIM)
or less.)
I certify mat in the performance of the work for which this permit Is laved,1 shall not -
employanypersoninanymonersouwbecomesubjecuotMWoleco'Compnsadon
Laws of California.Da¢ "
Applicant _
NOTICE TO APPLICANT:IL arm,making this Cci ifica¢of Exemption,you should .
become subject w rhe Worker's Compenstrion provisions of the Labor Code,you must
.J Z foMwith comply with such provisions or this Permit shall be d«mud moked.
z O CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a consvuctinn lending gcnty for the perrormmce or
C the work for which this permit is issued(Sec.3097,Civ.G
t11 Under's Name
z Lender's Address
U C I certify that I have read this application and sum year the auras infarmadan is '
D. r tortes 1 agree to comply with all city and county ordinamxa and we laws relating in
0U building construction.and hereby WO.me represemari.of this city to enter upon the
W alive-mentioned pimply for inspection purposes
(WO)agree to save.indemnify and keep harmless the City of Cupertino against
liabilities,judgments.costs and cxPerucs which may in any way accrue against said City
U Z Aconsequence of the gooling of r
LICANrUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dat
SOU CE RE LATIO Z
Re-roofs
Sign A Henn Contractor Date
HAZARDOUS MATERIALS DISCL Type of Roof
Will the applicanror future building occupant store or handle ha�ous material
as defined by the Capenino Municipal Code.Chapter 9.11,and tite Health and Safety
Code.OYor 25531(a)? AN All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
r haaardnus air conmminanu u JcOncd by rbc Bay Arca Air Quality Management all new materials for inspection.
in7
❑Yes XNu
Ihavemad theM7sm=dalsrequimmcnuunder Chapter6.95oftheCalifor-
niaRealth&Sdciy Cock,S«dou255r15,25533vd25534.1 undersendthmifthc Wilding
dies nor eurtemly havq a wnanr.Nar it u my rtsPemihiliry w rrodly the a<upant of Nc
rcquirtmen hkh s he to.pluessuarecoraccrific o apincy. Signature of Applicant Date
n«ora oro agentDate All roof coverings to be Class"B"or better