03120019CITY OF CUPER'I'INO
BUILDING DIVISION PERMIT
CONTRACInRzrINF,ORM TIQN
BUILDING ADDRESS:
PERMIT NO0 3 12 0 0 1 9
'10 HUNTERSTON PT,
R'S NAME:
PERMIT ISSUE DATE
)ZINA GERALD E AND SUSAN A
12/04/2003
ONE:
SANITARY NO. CONTROL NO,
ARCHM1 CIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
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1 hereby arum that 1 am licensed under provisions or Chapter 9 (commencing
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wire Sceuon 7W0)uf Dwislon3ofthe BusinGmmrd Professions Code.andmy license if
full foreeand effect.
icense Glasa.?aJ,G Lie.. �, 9azs
Date G9rlraContractormNALE®
LATTICE PATIO COVER.
DECLARATION
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1 unJcrsmnJ my plans aM1all sac trod as public mnnda
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6 2004
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Licensed Protestant ... I
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OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
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following mason. (Section 703 1.5, Business and Profcssiom Cade: Any city or county
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which requires a permit to construct, alma improve, demolish, m repair any structure
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:on
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poor III its issuance, also requires [he applicantfor such permit to G to a signed statemcm
License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
uraoano the pmm visloof the contractor:
W is licensed pu
(commencing with Section IME of Division 3 of Business and Professions, Code) or
Nat he is exempt therefrom and be basis for the alleged exemption. Any violation of
3 Oi2RIQMci0 0
Occupancy Type
Section 7031.5 by any applicant for It permit subjeess the applicant to a civil penalty of
not more than five hundred dollars (5500).
E3 1. as roomerofthe property. or my employees with wages as desirable compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sale (See. 704G, Business
and Professions Code: The Convector's Lice. Law docs nm apply to an owner of
property he builds or improves there... and who does such work himself m through his
n employee, provided that such improvements are not intended or offered for sale. If.
however, he building or improvement is sold within one year of completion, the owner.
builder will have the hrden of proving that he did not build or improve for purpose of
.is I.
1. as owner of Ne property, am exclusively contracting with licensed contractors 10
Construct the project (Sec. ]OCC, Business and Proressiom Code:)The Contnctens Li.
me Law docs not apply to an owner of property, who Wilds or improve themon, and
who com eacu for such projecm with a..munmon(s) licensed pursuant sU the Comment's
Lke. law.
I sm exempt under S.C. ,B&PC for Nis reason
Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one of Ne fallowing declarations:
❑ 1 have and will maintain a Ci nifieare of Consent to self-insum for Worker'sCompen-
sation, as provided for by Section 3]00 of the labor Code, for me paler UMCC of the
work for which Nis permit is issuctl.
and will maintain Worker's Compamadmis Imunnee, as required by Section
Chave1
'00 of the labor Code, for Ne perfrrman o of me work for which this Permit is issued.
My Workers Compensation Insurance Cartier and Policy number art:
Camcr. �i> ..."'�Li g�li�olicy No.:_? •00Lfit4r
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C RTIFICAn-OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
rlTusection need not be completed if Ibe permit is forone hundred dollars (SIM)
or less.)
1 cri ify that in the performance of the work for which this permit is issued. I shall not
employ any person in any mannerspi u to become subject to the Worken' Compenution
Laws of California. Date
Ar,dicmt
NOTICE TO APPLICANT: If, after making this ecniEcate of Exemption. you should
become subject to the Worker's CempCnaallrr previsions or me Labor Code, you must
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forthwith comply with such provisions or this Permit shall W deemed revoked.
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CONSTRUCTION LENDING AGENCY
I hereby a1Brm that there is a construction lending agency fat the Performance of
OC work for which this permit is issued (Sol. 31M, Civ. Cd
lender's Name
lender's Address
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1 certify that I have read ibis application and sum that me above information is
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cormcs 1 agree to comply with all city and county ordinances and sum laws relating to
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building construction. and hereby sutborim mpresenutisys of mil city to enter upon the
am,nt-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
Ind
liabilities. judgments. costs and expenses which may in any way ACCOM against Mid City
in of the pandoOrz APPLICACNTeUNDERSTANDSthis AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
5 RC E ATIONS.
Re -roofs
/x'4'03
nawrc of ApplinHAZARDor Das
HAZARDOUS MATERIALS DISCLOSURE
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Type Of Roof I
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Will me applicant Lir future building oacupanuore or handle hazardous material
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Fined by the CumirJon Municipal Code, Cbapmr 9.12, and the Health and Safety
. scenic. 255320)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes ON.
If a roof is installed without first obtaining an inspection, I agree to remove
Will mea Ikam or future building t use equipment or devices which
rap s«capon
emit hazardous air contaminants as defined by the Bay Area At Quality Management
all new materials for inspection.
District?
❑Yea No
I have read he hnaNtmsmaterials requirements under Chapter 6.95 Uf the Califor-
niaHcalth&Safety Code,Secdmu25505.25533a 25514.lundem=dmmifde Wilding
Does not etarci n hose we tenons mot it is my rcspomihllity m nodly tW «tupant of me
reqs wInmust Usrnarm a f.cortih.w.foccupoincy.
Signature of Applicant Date
• 4 -&3
All roof coverings to be Class "B" or better
0 it Unwed agent Dam