06060231CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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BUIL.DINGADDRESS:
J. DERICK & MARY DONAH
MITNo.06060231
20945 HANFORD DR
OWNER'S NAME:
PERMIT WUEDA S
. J. FREDERICK & MARY DONAHO
0712 6 2006
E:
SANITARY NO. CONTROL NO.
ARCHITEC/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
-
Job Description
on
t I Am nand under Provisions of Chapter 9 (Commencing
I hereby affirm WIke
P
with Section 70111) of Division 3oflhe Buuneas and Profnaore Code. a,tl mY littna u
nfmifarceanda�o- 27 �g7S�
CONSTRUCT COVERED PATIO. PATIO WITH SELF CONTAI
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Date IMCTI aewr
JACUZZI & HOOKUPS. ADDING GASLINE & ELECTRICAL
R HfIEC'S DECLARATION
I wWastand my pkre Nall M umd As public recarN�[AK/v('•/r'.7/ v
-- i
.are
spas /ria
Licensed Pmfe onal
OWNER -BUILDER DECLARATION
,
1 hereby affirm that I am Attempt from the COWWALL&a License Law far the
following mason. (Section 713 LA Business and Profeaaore Code: Any city or County
,
which requires a permit w ennsWc4 atter. Improve, demolW, Or reprir any rtrmmme
prior w its issuance. Abu requires the applicant for such permit to file a signed smtemcm
Contractors Unatx law (Chapter 9Sq.
F[. FloorArea
Valu L36 0 0
that he is licensed pis t roue provisions, of the
(commencing with Section 7000) of Division 3 of the segment and Pnefeuiom Cole) or
that he is esempt therefrom and the basis for Ne alleged asamptiaa My violation of
�u enc e
y T'P
Section 7031.7 by my applicant for a permit subjew the applicant w A civil PenatY ofP
rot roam than five hundred dalurs (3500).
3 2 63 0 U tl �t 0 0
❑ I.uowuer o(Aw proprsty,ormy emplayen with w{eauwetr xk eompauauon,
Required Inspections
win do thework.and the a ten ed .,offered 70c4.
ownerof
Longnue uence. law does Out appy lf rt roues
and Cade: The Camrxwrs curse La s Out apply
9 P
enyweore
his
improves thereon,andwho duessuchwoh himself is
propertywhobuilds ndwha
i ded methods forsae f.
overeer.
ofcoraRnet
she iprovidedmatvehimprowmnuamoatou
Owner.
huilden we buildingarimPmvemenng sueyear a ComPkuon, theoseor
builder will have We burden of proving tut he did rot bulb or Mprow for purpose car
test ed id
xk,)•
❑ 1, ru ogler of tow property, ,B exclusivelyand conuaNn{ with :) Tho d AUAWW`3 -
the prole, (Sec. 704E Broken and Pmfnaore Cade:) The Cootrxxrs
II�XXXX '
And
law don rot apply x ts owner of property who or impows thereon.Ons
. La
,
wfix
for such Projects with a eonaacwNO licensed punuanl x Ne Contrxmh
who gem(s sed sp
ust Lacu
License law.
❑ 14M nempt undo Sec . B k P C for this akasoo
r
net Data
WORKER'S COMPENSATION DECLARATION
I hereby aRbm under porosity of perjury ane of the fallowing dechationc
D l haw and will maintain• Certificate ofCoreeni to self -Inure for Warker's Compen.
salon, As provided for by Section 3700 of the Labor Code, far de performance of tee
work for which this permit Is Issued. .
D 1 haw and will maintain Worker's Compensation Insunnw, As required by Section
3700 of the labor Code, far we performance of the wmrk for which this permit u issued.
'
Myth, ker or�Co�mp, e/reation huurmcarrier and Policy number son:
Co
Gsriee ��^'mac-•�i�0; Policy No.PM&903 '1 IL
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Obis mcnlar, need amt Mconpleua If ft permit is feran, hundreddunars (x100)
W ICs&)
I conify that in the performance of dte work rue which this permit is bound, I Nal no
employ any person in Coy manrerx as to become subject w he Workars'Conpreador
I. of Caifomia. Dau
Applicxl
NOTICE TO APPLICANT: IC after making this Certificate of Exemption, you should
become subje, x the Workers Compensation previsions of we labor Code, you mug
foMwith comply with such pnmouns or this permit Nal W domed revalued.
CONSTRUCTION LENDING AGENCY
I wroby affirm COAL wort k a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3071, Civ. G
Lenders Name
Lenders Adnm..
1 certify that I haw read this application, aro suis war the above Information u
core,.1 agree to Comply with all city sed county oNinwco and sou laws relating to
building conswolian, and hereby xworim mpmacnutivu of this city to enter upon the
above-meadmmed property (or lnapecYan purpose.
(We) agree to sew, indemnify and Leap harmless the City of Cupertino gems
j Iiabiliva.Judgmenu.tasu and expenses which may In say way accrue agawsm mid City
In conxq of the I=Ung of this rcOMIL
APPLI ERSTTAyNDS A D WILL COMPLY WITH ALL NON -POINT
Issued by: Date
��/�6 7 'g`/0
Re -roofs
Type of Roof
urt of Appli HAZARD SMATERI DISCLOSURE rtoodurracturl Dau
Will the applinnt m future building oocupmt gore or handle haallous materia
;e.i,
ned by the Cupertino Municipal Cade, Chapter 9.13. and the Heath and Safety
Semen 35533(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑YesWill
a roof is installed without first obtaining an inspection, I agree to remove
tow Applicam or fmurobuilding Occupant use equipment car devices whichIf
naNnm air Con.I.%u defined by we Bay Ana All Quality Management
all new materials for inspection.
District?
Dyes ?1Nu
1 have real we hnallous matedas rtquinmenn undttChaptor 6.95afwe Calif.,.
nia Hcalth cry Cade. Sectians 2570.7,35733 and 35734.1 undenund the l(We building
does vel all haw a tean
nt. thati my (Gatto ity w Deify the oaupant of we
mquiro , ohm It wBCo c Gmgaeteofa prey.
Signature of Applicant Date
All roof coverings to be Class "B" or better
mer Dr auwerl]Ld agent _ /bawl
7