04060160V2
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CITY OF CUPERTINO
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DIVISION PERMIT
r C,O,NTRACTnR INFORMATION _
BUILDING
BUILDING ADDRESS:
PERMITNO0 4 0 6 0 16 0
10560 E ESTATES
OWNER'S NAME:
PERMIT I SUE DATE
JERRY STEVENS
06/18/2004
9E:
SANITARY NO. CONTROL NO.
ARCHM-C IENGINEERI
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
o
al I am nsed under provisions of Chapter 9 (commencing
I humbly affirm Nlice
P
with Section 7") of Division 3.f the Busioeex and Professions Code, and my license is
infull force ameffect.
ADD 137 SQ. FT. (LIVING ROOM)
Liccnw Class Lic.g
,
Date Contactor
ARCHITECPS DECLARATION
1 undc.und my plans shall be used as public memos
Licensed Professional
OWNER-BUIIDER DECLARATION
I hereby affirm that I am exempt from the Contmctors License Law for the
following mason. (Section 703 1.5, Business and Pmfcasiuns Code: Any city or county
which mquin. a permit m mnuwct, alter, improve, dcmrobb. or repair any structure
$20000
prior N its issuance. also meti ms the applicant for such permit to Glc a signed statement
Sq. FL Floor Area
Valuation
that he is licensed liunuml1. the provisions of the commew', Lieenw l.w(Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Profaasions Code) or
from he is exempt Ihmefrom and do basis for Ne alleged exemption. Any violation of
Df
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicanuo a civil penalty of
not mom Nan five hundred della. (5500).
❑ 1. as owner of the pmperty, in my employees with wages as their solo compensation,
Required Inspections
q P
will do the work. oil Neswctum is no, intended or Rased for salc(Sec. 7004. Businw
and Professions Code: The Contractors License Law does not apply to an owner of
erty who be, bime,lfofNrough his
employ b.pmvids rimprotu Nempnand who
/� tI
am not l umdc
Own provided that such improvements art not intended or oelred for ula.lf.
Own
HN
howcvcq the building or impmmmem is roto within ane yes of completion, the owoer-
�puVIry14`//..\~\�\1IIpIS
builder will have the burden of proving Nal he did not Wild or improve for purpose of
rel ).
1. as owner of the propeny, am exclusively contracting with licensed commemor to
SEP 0 8 2004
construct the project (Sec. 7044, Business and Profusions CodeO The Conuacwr's Lt.
cone, Law does not apply to an owner of property who Wilds or improma Neuron, and,
who Lau rsuN rojccu wiNacontracmrts7litenwd pursuant to Be Convectors
License taw.
❑lam exempt nder c. B A P C for this mason
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'I'1. '1B"
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WORT Fj1'S COMPENSATION OECLA\f>,D7
I hereby affirm under penalty of perjury aro of the following declarations:
ham and will maintain aCenifiam of Consent m self-iuure fro WorYeri Compen-
tion, provided far by Section 3700 of the Labor Code. for Ne Performance of the
u
work for which this permit is issued.
1 have and will maintain Workces Coreperuelion Insurwce, as required by Section
37W of the Labor Code, for the performance of the work for which Nis Permit is issued
-
My Wmkers Compensation Inwnnte canner and Poli, number art:
Carriee Poli, No.:
'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Mie section need not be completed if the Permit is foronc hundred dollars ($I00)
or I..)
1 certify Nat in the performance of fee work for which this Permit is issued. I shall not
employ any person in any manner so as to become subject to the Worker' Compemation
Laws of California. Dem
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code. you mute
' forthwith comply with such pmvlsinns or this permil shift W deemed mvoked.
CONSTRUCTION LENDINGAOENCY
const
berchy Nerc is construction 3 lending agency for the performance of
which
' the work for which Nu permit is issued (Stt. 3097, Ci, C.)
pe
Lenders Name
Lender's Address
j 1 terrify 0.11 have rtad this application and state Nat the above infmmation is
• correct 1 agree to comply with all city and county ordinances and mute laws relating to
building construction. and hereby author m mpresenutimf of this city to enter upon the
mow mentioned pmpcny for inspeeoon purpose.
(We) agree to um, indemnify and keep harmless the City of Cupertino against
i Iiabililms,judgments. costs and expenses which may in any way accrue against sold City
inconsequence f Ne g oung of this Permit.
APPLICANT NDER TANDS AND WILL COMPLY WITH ALL NON -Po NT
SOURCE REG LATIO S. /_,16r 4
Issued by: Date
Re -roofs
Type of Roof
(V
gnomic Iicauractor
HVAZA�RDOUS MATERIALS DISCLOSURE ate
Will Iha applicant or future building occupantstom or handle hvallous material
as defined by the Cupertino Municipal Cade, Chapter 9.12, and the Heald and Safety
Code. Section 25532(a7? -t
All roofs shall be inspected prior to any roofing material being installed.
�YOyer�LNo
If a roof is installed without firs[ obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devils which
harardoor air conmminanu u dcfincd by Na Bay Ama Air Quality Management
all new materials for inspection.
soict?
❑Yes <No
1 have mad the havardnua materials requirements under ChaPlcr6.95 ofthe Califor-
niaHcalN&SafetyCode, comes 255(15,25513 am125534,1 undcruvWthtdone Wilding
dos nal emmm hoe a rant, Nal it is my maponaihility m nooly the Occupant rel Nc
Mgdcormts wh III mast met poor m issuance of a CeroOea oflxc ancy.
Signature of Applicant Date
- r D
All roof coverings to be Class "B" or better
nor or wmpdvcd aged