99090123 (2) CITY OF CUPERTINO "` °^ -'' ° "nY � ,'g,. - ';, -
BUILDING DIVISION PERMIT CONTRACTOR NFQRMATION.
BUILDING ADDRESS: PERMIT N09 9 0 9 0 12 3
7580
OWNER'S NISSUE PERMIT UE DATE
SIMMONS JAMES ID JR
ONE: SANITARY N0. CONTROL 10.
ARCHITEC(ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
>✓a p LICENSED CON-D ACTOR'S DECLARATION
y G 1 bercby affirm that 1 am licensed under provisions or Chapter 9(commencing Job Description
:5a:at wide Section 7").f Division Sof the,Busieas we Professions Code,and my licensee
in full force and effect. BATHROOM REMODEL Fy
Stjse License Class Lic.M
ttl ARCHITECTS Connector
?w� I understand my plans shall W used as public records
3 G 5 Liccnscd Predcssi...I PR
OWNER-BUILDER DECLARATION 7 O
I herchy affirm that 1 em exempt form the,Continence.License law for the l,wL 1 ynoO
cc following mason.(Section 7031.5,Business and Pmfesvlons Code:Any city or county Y d j 4-d XII �I
$ which rcquirca a permit In construct,ehel,impmve,demolish.Or.pair any swam.
Prior N its issuance.also redid.the applicant fo...ch permit to file a signed ata.mem
that he is licensed pursuanuelMpmvisionsOfd.Contncmr'SUwpaclaw(Chaphe9 Sq.FL Floor Area Xflluation
ecFG (commencing with Section 7000)of Division 3 of the Business and Professions Cutle)or f�LLdd
i 5 3 that be is exempt therefrom and the base for the alleged exemption.Any violation or
Section 7031.5 by any applicant for a permit Subjects dee applicant o a civil pushy of 35*y?IlNd2r5et00 Occupancy Type
not more 00.five hundred dollars($500).
❑Lasowrr.rofthe Psop.rty, re is omployces widewageas Heirsol.rom.Business
will do@ewmk,and dee Strum.isures Licenraled se
not does
(Sec.be W144.Business
of
and Profession,ora code:nnbetir convenor.Lime oca does ret apply to an owner rr Required Inspections
owniunwyees,provided e,suoves thunpraMwho Eoes.uchworkhimselfrn through he
own employees,provided that such impro old within
not ea:ofc oroReed for sale.If,
however.the Wilding or improvement is sold within eeyear or improve
the use of
builder will have pie burden of Droving WI M did not Mild or improve for purpose of
sale.).
O 1.as owner of the property am exclusively contracting with licensed contratu rs N
construct circ project.(Sec.o an owner
of and Pmfexo Wilds
Code:)The ConvecNrY Li- ��^ _���
cense Law docs not applytoan owner of property who Milds ar improve Contra,and Ikll�4\yl II
who contracts for such projects with a convacmr(s)licemed pursuant m dee Contractor's
Lkcnx law.
❑I am exempt under Sec. .B&P C for Nis moon APR 1 02000
Owner Date
WORKER'S COMPENSATION DECLARATION eeww..
`J7C37W
I hereby affirm under penalty of perjury one of cine following detentions: l}eltl llOtl ®Bp��
I have and will maintain a Cerifinte of Consent to self-insum for Woken Compare- asta�U try Ntl
nion,u provided for by Section 3700 or the labor Code.for the performance of the
ek for which this permit is isa cd.
1 have and will maintain Worker's Compensation Insurance,as requied by Section
of dee labor Code.fee the performance of the work for which the Note is issued.
y Wrrknes Compuvsadon Insurance anis and Policy number ae:
rtier, Policy No.:
CERTIFICATE OF EKEMMON FROM WORKERS'
COMPENSATION INSURANCE
rine senior nead noticcomplued if the Permit isforone hundred dollars($1007
or less.)
I unify the in dee perfmmanc.of Ne work for which this permit is issued.I shell out
employ any person in any manncrso as As become subject to NC Workeri Compensation
Laws rf California.Be.
Applicant
NOTICE TO APPLICANT:If.after mating this Certificate of Exemption,you should
Intermit,subject to the Worker's Compensation pmvisions of Ne Labor Code,you most
.JO frMwith comply with such provisions or this Permit shall W deemed revoked.
ZM CONSTRUCTION LENDING AGENCY
[—ice Ihe.hyaffirm that Vert is a construction lending agency for the Performance of '
Ci the work for which the permit is issued(Sec.MD.Ci,C.)
A lenders Namc
= Z Lender's Add.A
U Q I ttNry Nat 1 have red Nis appliatirn and sate Nat Ne ebow infra .due I. ,
W F correct I agree to comply with all city and county ordinances and state laws elating in
0U building conswction,and hereby auNoin repoaenmives of this city to enter upon the
W abovcmemionedpmpeny for inspection which ms
f-r 41, (We)agree to save,indemnify and keep hasmless the City of Cupcnino against
flabilIn inc.itics,jud..1theSoso and expiA pc.iich may in any way acrn.agaiw said City
U Z APPLICANT
UNDERSTANDS
of this D WILL
Issued by: Date
^' APPLICANT UNDERSTANDS ANO WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
Signature of ApplicaDem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant no forum Mal Ciek.Chapter
no.or handle h eardoas material
u defined by Ne Cupertino Municipal Code.Chaptor 9.13,and ILS Health and Safety
Code.Section 2553](x)?
❑Yrs El No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or return building occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
mit harudous air contaminants As defined by the Bay Arca Air Quality Management all new materials for inspection.
ni
isaict7
❑Yes I-]No
I have read the hit-rd.,malcri ils.quiements under Charter 6fon
95 of the Cali
rte Halt h SafnyCodc.Sections 25505.25533 and 25534.1 undensuM the if the Wilding
D
dies t cwmntly have:a toneduer, �it a my espomm am de
iably nodry the aeupof
requirements which mustM met prior ser issuance of a CenlOcate of Occupancy. Signature Of Applicant Date
Owner oraut o tcdagent Data All roof coverings to be Class"B"or better