06050092CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
JAYNE HAM
PERMITNO.06050092
22390 HOMESTEAD RD
OWNER'S NAME:
PER` 17L55UEDATE
JAYNE HAM
06/15/2006
E:
SANITARY NO. CONTROL NO.
ARCHIIEC iENGINEER:
BUILDING PERMIT INFO
BLDO ELECT PLO MECH
LICENSED CONTRACTOR'S DECLARATION
lob Description
Job
I hand, air,. Nat I am licensed under provisions of Chaper 9 (commencing
with Sudan 701111) of DMsion 3afde Business and Prormsiom Cada,nW my Ikea¢ 4
tLt.. l.tfoC' arta ere
h(o( 5 S
300' PATIO
_Lie a
DECLARCormomatuar �ON
Delo /st n fano"I
gpry� {Jgq{j� Ir'7p{���
I msdersunJ my Plw NJI w used u public lecords
be
FINAL yP
Licensed Pmfassio..I
OWNER -BUILDER DECLARATION
1 hereby olRrm that i am exempt from dm Conuackrs License Law for Ik
following antsm. (Sudan 703 1.5, Business and Professions Cade: My city or county
O.0 O O
which lequlmet a permit to construct. altar, improve, demolish, lir repair any sanctum
3
prior do its issuance, also requires the applicant f«sach permit un It asigrod tutamen
that he is licensed placement to de proviaiomaf the Comments's U.. Law (chapter 9
Sq. Ft. Floor Area
(commencing with Section 70OX or Divalon 3 of the Businessand Profeulma Code) or
that he 4 exemps therefrom and the basis far Ne allegW memption My violation of
Sudor 7031.3 by any applicant for a permit subjects the applicant to a civil penalty of
eT
Occupancy Type
cwt more and ave bundled daltam ($3007.
❑ 1, u ownv o(ds property. «my wpkyees veld wages u meta sale campenudon,
Required Inspections
win dkwan. ands a
Comadoemkndnse anetm r,
to ocratuty
siam Cade: The Convectors License Law den oat apply k lt awncr
and Professionsan, apply
r The
q I7
is
Property and subs amaauehwonhimsJ(ardwugh his
whovelpro
Nm aueh lmProvemew ale ms insMW maQanL
Own un provided improvements
own emplayeWildin
year or couple the p.or-
the owner. howeeer, the building
or i improvement 4 veld wllhina
u t for
"Iam MR have the wcdan of proving Na k did nm build or improve f« purpose of
❑ 1, as owner of the property am exclusively, embracing with licensed mnuaswn to
contract de pmjem (Sec. 7014. Business and Profcasiom Cade) The Commodes Li-
cense Law does cot apply to an aww of property who builds m improve, mtakm, ad.
who contracts for such Projects with a convactar(s7 licensed pumomm in the Contriames
License les..
❑ lomcaemptunder See. ,Bh PCfarthim.
0. Data
WORKER'S COMPENSATION DECLARATION
1 hereby offices under pcvalty of perjury ane of the following dm3aruimve
l have and will maintain a CeolOcae ofComem an self-im ref«WortrrsCompm-
ami m, as provided for by Sudan 3700 of the Labor Cade, far the pertomance of de
wan for which this pact, 4 issued.
❑ 1 have and will maintain Workers Compensation Insurance, u required by Sudan
3700 of the label Cade. fm due performance of the won for which this permit is Won[.
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My Workers Compensation Instrument cariar and Policy number ale:
Carom aneL rt't� Policy No.:'7)SIM mss
CERTIFlCA OF EXEMPTION FROM WO KERS'
COMPENSATION INSURANCE
from; urian need Out bccomplekd Irthe permit Is f«one hundred dollar (SIM)
or kis)
I canary that in the performance of tem won for which this Permit Is 4tmd,1 shall Out
employ any person in my manner an Is an became subject an the Woaem' Compensubm
Laws of California. Data
Applicants
NOTICE TO APPLICANT: If. aRcr making this CeolOcak of Exception, you should
become subject to the Workers Compensation provichas of due Lab« Cade. you am
foMwith comply with such pmvWom or this permit "I bre deemed uveked.
CONSTRUCTION LENDING AGENCY
agency f«mk Pcrfwmanm of
1 hereby aRrm Uses des Is a ronsSm.30
7.ming
Ne work for which dna pemtis a ¢sued (Sm. 7097. Civ. Cd
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Lenders Name
'
Lenders Mdm•a
1 I molly that 1 have read this application and cut mut the above Information is
comet. I agree to comply with all city and county ordinances and arms laws refusing an
Wilding construction, and hereby authorise mpnecanudwe; of this city to enter upon due,
7 above-mendumd p r rsay for inspection purposes.
(We) agree ro mote, indemnify and trop homeless the City of Cupertino against
i liabilities, judgmcnu. costs lib ax,., which may In any way sunk agtloot cold City
In comegonce of de granting or tai reels.
' APPLICANT ERSTAN W MPLY WITH ALL NON -POINT
Issued by: Date
SOURCE gnDNS
�1J
Type of Roof
/_ 1 ( 44"Re-roofs
Signuule P HAZARDOUS MATERIALS DISCLOSURE
Will the applimnt m future building oceupantmole. handle huaolom metrial
u de0md by the Cupeolno Municipal Cade. Chapter 9AZ and the Health and Safety
Code, section 25532(a)7
DYe, �Na
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will cit, neat ar future wilding Occupant at t or Mvlats which
pp e,
emit huaolow cis contsmimnts u tkRnea by cit Bay Ama Air Ourelity Mwgcment
a Ail C
all new materials for inspection.
Disuict7
`e�,.,(
❑Yes .
1 have mad the haraNmu maerialsmquhemmm unecr Chamerli.93 ormt Califor.
e,4 Hc91thk5afcYCade, 103.233 75174.IwsanauM thnl(IM wilding
does nate t haveo 110 mimlisy m maty Ne occupantnlde
lequllemc It In mat art of. cmdrtatar
Signature of Applicant Date
All roof coverings to be Class "B" or better
�e
Own ermam art ag<nt