07120256CITY OF CUPERTINO
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BUILDING ADDRESS:
1111 DERBYSHIRE DR
ROCKWOOD CONSTRUCTION CORP.
PERMITNO.
07120256
W NER'S NAME:
PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
(408)868-9026
AR CHTIECTIENGINEER:
BUILDING PERMIT INFO
'BLDO ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby arm that I un heenmd under provisions of Chapter 9 (commencing
with Section 7000)of Division 3 of the Business and PmRssions Code. and my leans is
ADD 524SQ OF LIVBLE AREA, MV BTHRM,ADD BAY
in full forte andefrecc
Llanm Cm. La.0
WINDW,ADD BTHRM TO MSTR BDRM, RESIZE 2 RMS, MV
Dam Contractor
ARCHTECT'S DECLARATION
KTCHN
1 undewnd my plane Nall he used u public records
Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affure that 1 am exempt from the Conlraamr's Ucenm Low for the
following mason. (Sectim NO 1.5, Business and Professions Code: My city at county
which Ie9dre3 a Permit to conelNel. alta. Improve. demolish, or mpmr my RNmum
prim m ISS Issuance. atm requires, the applicant fm such permll to rile a signed statement
that the ielicensed toMeofMe, Contractor's limmmLaw (Chapor9
Sq.Ft. Floor Area
Valuation
Panama provisions
200000
Saturant with S'eti7000) of Division 3 of the Business and Pr.feW on Code) or
dol he is asompt Nemfrom and the basis for the alleges esomption. Any violNon of
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Occupancy Type
Section 7031.5 by any applicant for a permit subjects Ne applkanno a civil penalty ofNumber
nm mom than ft. hundred dollars (am3
6 2 2 0 0 2 6
❑ I, ss owner of Ne prvpmty, m my wplaym wW wgn u Neo role compcnssti.n,
Required Inspections
will do the work and thestrochon ismaimmuled or.flared for sale (Sec. 7041, Budness
and Pnefemu Cade: The m k License Law does t apply an Owner of
m Conumrrom
property w lm bui lde m ire prows Nenmn, and who doas aah wank himself. m thmugh his
own employees. provided thalm'h improvements w nmimemied aro@rod fmsak If,
areae er, Ne building as improvement is sold within mw year of complo loa. the owner-
hmldcr, will have the burden of proving that M did rot Mid m imprme for purpose of
ole.).
❑ 1, as owner of the property. .m exclusively'omnming with licensed mnuamom m
mrotmes dw project (Sae. 7344. Business and Professions Code:) The Commemr'a u-
come Law does not apply m an Owner of property whe Miss or improves Nemon, and,
wMemv.cu fm such pojema NN a emuremrta) Hamed pursuant m the Conummfs
Lice. Law.
❑ 1me stomp, under,ec_ BkP Q for Wsmoon
caner Data l Y
WOq
IheInby.mtm miler en.uy of perjury one of the mllowing deeW.tiw:
� .
❑ I love and will maintain. Certifiaw o(Commnt m self-oume fm Woder's Compco-
.do., u provided for by Section 3700 of the Isbm Code, fm the Rrfmmena of Ne
work for which Ni. permit ie Issued.
❑ 1 have and will maintain Wmkr's Compensation IrtsWame, as m{dmd by Section
3700 of tie Isere Code. for the imsf maof Ne work fmwMm Our permit Is ieeaa.
.
My Workees C.mpeasatian I mrana amen and Policy number are:
Carver: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This mors reed mtbecanpkmd U f permit is fm.m huMrtdd.imn(Slee)
.r moa)
1 anify Not in the performance of the work for which this panni, is Issues. I shell net
employ any person in my manner an u in bee rep mbjatmthe Workers, Compensation
Laws of
Laws of Calif.mia, Da1eti..—L
Ig'"'- R6V
NOTICE TO AP h7f: If. a r making this Cenifie w .f Exemption. you Nould
become subject to Ne Worker's Compensation provisions of the Labor Code- you muss
forthwith comply with such Provisions Or thio permit mail be dames Invoked.
.
CONSTRUCTION LENDINGAGENCY
1 hereby affirm Out Nem a. monstrminm mrding.gency fm Ne performrna.f
the work fm which this Permit is issued (See. 3091• Civ. CI
'
lender's Name
,
Lender's Address
I ceNfy Nas 1 have man this application and sow Nu Ne above information Is
'
torment. Lame to cmnply with MI city and county ordinance. rad fess laws relating to
b.Rding construction. and hewby mmadm repmsenwlves of this city m an upon tie
'bore-mentioned Property far Inspection Purpmer.
(We) agree to Mr., indemnify and keep hamdess dm city .f Cupertino against
liabilities, Iudgercms. cow and expema which may in my way acorns against said City
in con ucoce.f the granting of this permlt.
AP
Dam
HAZARDOUS MATE RIALS DISCLOSURE
WIII applicanlno hazardous
builopal
.rand
Muni
ode. Chapter 9.12.
as dented by de Cupertino Municipal Code. Olrpwr 9.13, and the Ho1N and Safety
M HWMand
0"'•sa"i°nv5'3(')+
All roofs shall be inspected prior to any roofing material being installed.
❑Ya ON.
If a roof is installed without first obtaining an inspection,agree to remove
Will the applicant or future building occupant use equipment or de.Ia, which
.I
emit 1144mm m air contaminants as deRmd by Ne Bay Area Air Quality Mmeg'ment
all new materials for inspection. .
District]
Oyes ONO
1 have read the bacard. materials requirements took, Chapter 6.95 ofthe Califor-
ni.H.atN&SafetyCese,S.6.as35505.35533and35334.1mdemand Nmifthe building
dao mmntiy have a ton that It is my responsibility m notify the meupant of the
Ingd T.Cmencim MA.t
l
Signature of Applicant Date
All roof coverings to be Class'%¢ or better
owoerara t r<dagent Dam