04070092 CITY OF CUPERTINO '
PERMIT t .:...?➢'.:'m Ci.h. TR:l.. Ni 3F.O', RMk AT` IO':sere'N
BUILDING DIVISION T �
'
BUILDING ADDRESS: JERRY STEVENS PERMITNQ04070092
10566 E EST=
OWNER'S NAME: - PERMITISSUEDATE
JERRY STEVENS
E: SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
Boa LICENSED CONTRACTOR'S DECLARATION Job Description
ss u F I herebyherebyNm li
by affirm al I am op
cd under provisions of Chapter 9(commencing
<I with Section 7")of Division 31fthe Business and Pmfcssiuns Code.and my license is
^<n in minora nandefr«t. FOUNDATION REVISION
,,OZ License Class Lic,a
x�o Da Cdn ", ORIG PERMIT 04060160
^''� ARCHnECTS DECLARATION NO NEW PERMIT ISSUED
1 understand my plans shall k used as public records,
Dau
3 a Licensed Professional
03
OWNER-BUILDER DECLARATION
Ccom ON
0 0 1 hereby affirm Out 1 1. exempt from the Gamonts C s License Law for the
O yOy following mazoa Permit
t ]1131.5,Business and improve,
de tins Code:Any city or county
4 m LL w11ie11 requires;a perrnit m CnaSWCI,aIMC improve,dCmollfih,Or repair any Rtrvcturt
m�'^ prior In its issuance,also menoms the applicant for such permit to fie a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
y0x
fp
(commencing with Section tion 7 )pf Division Business Professions Cow) O
,5§ that W is exempt thenefrom and The bass for doe alleged exemption.Any violation of Y
Section 703 1.5 by any applicant fora permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom than five bunched dollars(S500). h
L as owner of the propwry,m my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale(Sce.7014,Business
and Professions Code:The Connaght's Lleenu law docs not apply or an owner of Required Inspections
progeny who Wilchm to moses Noreen,andwho daessuchwork himselfor through his
own employees,provided that such improvements art not intended or offered forsale,IL
however,the building or improvement is sold within oto year of completion.the owner.
builder will have the burden of proving that he did not Wild or improve for purpose of
ale)as owner of the property,am exclusively contracting with licensed conu elors to
co met Ik project(Sec.7W.Bochum,and Professions Code:)The Contractors Li-
cense law docs not apply to an owner of property who Wilds or improve Ihemon,ad.
who contacts for such post with acomeactor(s)licensed pursuant to the Com actors \
License law.
❑lamt�otundw Se B&PC ar Nismvon
WORKER�PENSATION DECLARATION
I hereby affirm under penalty of perjury one of the fallowing declarations:
1 have and will maintain a Cer ificate arconsont m self-insure fur Worker'sCompen-
ation,as provided for by Section 3700 of the labor Code,for the performance of Ne
work for which this permit is issued,
❑I have and will maintain Worker's ConaMmalion Insurance,as required by Section
37W of the labor Cods.for the performance,of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu swoon reed rant k eomplcmd Hthe permit is foronc hundred dollars($1IX)
nr less)
I unify that in Ne performance of the work for which this permit is issued,l shall not
employ any person in any manner an as to wcomc subjcn to Ek Workers'Cempcnsatien
taws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Cenificalc of Esemption,you should
become subject to the Workers Compensation provisions of the labor Code,you mug
.J O forthwith comply with such provisions or this permit shall k deemed revoked.
z CONSTRUCTION LENDING AGENCY
P' 1 hcmby affirm Nat there is a construction lending agency for theperformance of
C4
7 the work for which this permit is issued(Sec.3119'1.Civ.C.)
ZLender's Name
z Lenders Address
V C) I cenify that 1 have read this application and sahe that the above information is
L4 F' coven.l agree to comply with all city and county ordinances and Vale laws relating to
O V building congroction,and hereby authorise representatives of Nis city m enter upon the
C m
above- entioned property for inspection purposes.
purpose
(We,)agree to ave,indemnify and keep hafmleas the City of Cupertino against
f' N liabilities,judgments.costs and expenses which may in any way acomc against aid City /fry
U z APPL CANT UNDER'of the g NDSItis
lperW ILL COMPLY WITH ALLNON-P01 Issued by: to
SOURC R ATION
Re-roofs
erre Applican Irecor,
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hmardous material
as defirsed by Ik Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Ycs Nu
Will Nc applicant or future building eccupam eccyuipmcnl or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Cork hanfdrus air contaminants as defined by the Bay Area Air Quality Management all new materials for Inspection.
S District?
Ycs nu
I have read!the Isoard/ous material requirements under Chapter 6.95of dm Califor-
ouHealth SkSafetyCwc,Sce"ors,25505,25533pund 25534.1 understand Natifthe Wilding
does not currently hank v tenant Il li my pprr5lllilily m nOtl Y BC 0.Yrparll of lk
mquimmcn mu ramal- rmisaa mCcrtde.cofDecpree.. Signa[ureofApplicant Date
r
net or out axed agent Date AI I roof coverings to be Class "B"or better